Provider Demographics
NPI:1659512390
Name:WASTROM, JOANNE
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:WASTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:
Other - Last Name:WASTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DENTAL HYGENIST
Mailing Address - Street 1:50 REDFIELD ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3630
Mailing Address - Country:US
Mailing Address - Phone:617-506-5160
Mailing Address - Fax:
Practice Address - Street 1:30 ELM AVE
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5547
Practice Address - Country:US
Practice Address - Phone:508-778-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5164124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist