Provider Demographics
NPI:1518269810
Name:WEST SOMERVILLE DENTAL
Entity Type:Organization
Organization Name:WEST SOMERVILLE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARHAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVI-SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-625-0543
Mailing Address - Street 1:124 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1919
Mailing Address - Country:US
Mailing Address - Phone:617-625-0543
Mailing Address - Fax:617-666-5034
Practice Address - Street 1:124 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1919
Practice Address - Country:US
Practice Address - Phone:617-625-0543
Practice Address - Fax:617-666-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1223G0001X, 1223P0300X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty