Provider Demographics
NPI:1851172266
Name:HEREDIA, SALATIEL ELIUD
Entity Type:Individual
Prefix:
First Name:SALATIEL
Middle Name:ELIUD
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PLEASANT ST APT 205
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4467
Mailing Address - Country:US
Mailing Address - Phone:781-269-1740
Mailing Address - Fax:
Practice Address - Street 1:20 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1201
Practice Address - Country:US
Practice Address - Phone:781-581-9832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADA08559126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant