Provider Demographics
NPI:1790016368
Name:FIDELITO GABRIEL DMD PC
Entity Type:Organization
Organization Name:FIDELITO GABRIEL DMD PC
Other - Org Name:FOREST HILLS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDELITO
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-763-9351
Mailing Address - Street 1:5 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2507
Mailing Address - Country:US
Mailing Address - Phone:617-522-7414
Mailing Address - Fax:617-522-1425
Practice Address - Street 1:3724 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3701
Practice Address - Country:US
Practice Address - Phone:617-522-7414
Practice Address - Fax:617-522-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty