Provider Demographics
NPI:1942202023
Name:GESCHELIN, EDWARD VANCE (DMD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:VANCE
Last Name:GESCHELIN
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 1:500 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4406
Mailing Address - Country:US
Mailing Address - Phone:617-268-2333
Mailing Address - Fax:617-268-8894
Practice Address - Street 1:500 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4406
Practice Address - Country:US
Practice Address - Phone:617-268-2333
Practice Address - Fax:617-268-8894
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0256897Medicaid