Provider Demographics
NPI:1639591704
Name:ORTHODONTICS OF MELROSE
Entity Type:Organization
Organization Name:ORTHODONTICS OF MELROSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSHANAK
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAZINOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-662-7880
Mailing Address - Street 1:21 E EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3520
Mailing Address - Country:US
Mailing Address - Phone:781-662-5246
Mailing Address - Fax:781-662-5246
Practice Address - Street 1:21 E EMERSON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3520
Practice Address - Country:US
Practice Address - Phone:781-662-5246
Practice Address - Fax:781-662-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17415261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental