Provider Demographics
NPI:1629341540
Name:DAVIS SQUARE DENTAL GROUP
Entity Type:Organization
Organization Name:DAVIS SQUARE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:RIZKALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-872-4499
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:
Mailing Address - Fax:
Practice Address - Street 1:30 COLLEGE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1914
Practice Address - Country:US
Practice Address - Phone:617-764-2247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty