Provider Demographics
NPI:1740230259
Name:COLCHAMIRO, STEPHEN (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:COLCHAMIRO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3297 WASHINGTON STREET
Mailing Address - Street 2:BROOKSIDE COMMUNITY HEALTH CENTER
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-522-4700
Mailing Address - Fax:
Practice Address - Street 1:3297 WASHINGTON STREET
Practice Address - Street 2:BROOKSIDE COMMUNITY HEALTH CENTER
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-522-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11321122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist