Provider Demographics
NPI:1336266980
Name:EL SHADDAI DENTAL
Entity Type:Organization
Organization Name:EL SHADDAI DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLATUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:DM D
Authorized Official - Phone:781-986-8800
Mailing Address - Street 1:1134 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2130
Mailing Address - Country:US
Mailing Address - Phone:781-986-8800
Mailing Address - Fax:781-986-1600
Practice Address - Street 1:1134 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2130
Practice Address - Country:US
Practice Address - Phone:781-986-8800
Practice Address - Fax:781-986-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA196211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty