Provider Demographics
NPI:1942418223
Name:TAVARES, MARY ANGELA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANGELA
Last Name:TAVARES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:TAVARES
Other - Last Name:SUTULA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:140 FENWAY
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3782
Mailing Address - Country:US
Mailing Address - Phone:617-892-8261
Mailing Address - Fax:617-892-8431
Practice Address - Street 1:140 FENWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-3782
Practice Address - Country:US
Practice Address - Phone:617-892-8261
Practice Address - Fax:617-892-8431
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA138091223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health