Provider Demographics
NPI:1396204335
Name:DAVIS SQUARE DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:DAVIS SQUARE DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-591-9999
Mailing Address - Street 1:30 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1914
Mailing Address - Country:US
Mailing Address - Phone:617-591-9999
Mailing Address - Fax:
Practice Address - Street 1:441 CHATHAM ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-2139
Practice Address - Country:US
Practice Address - Phone:781-599-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVIS SQUARE DENTAL SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty