Provider Demographics
NPI:1912357336
Name:REVERE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:REVERE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAR
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BALOUL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-284-3113
Mailing Address - Street 1:11 VINAL ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5326
Mailing Address - Country:US
Mailing Address - Phone:781-284-3113
Mailing Address - Fax:
Practice Address - Street 1:11 VINAL ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5326
Practice Address - Country:US
Practice Address - Phone:781-284-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN206031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty