Provider Demographics
NPI:1417399270
Name:WAHID MISTIKAWI DBA GREATWOODS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:WAHID MISTIKAWI DBA GREATWOODS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:MISTIKAWI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-339-4171
Mailing Address - Street 1:792 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-3137
Mailing Address - Country:US
Mailing Address - Phone:508-339-4171
Mailing Address - Fax:508-339-8311
Practice Address - Street 1:792SOUTH MAIN ST
Practice Address - Street 2:24
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-3137
Practice Address - Country:US
Practice Address - Phone:508-339-4171
Practice Address - Fax:508-339-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN17639305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization