Provider Demographics
NPI:1952013518
Name:BANO, ERISELDA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERISELDA
Middle Name:
Last Name:BANO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CASS ST APT 7
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4820
Mailing Address - Country:US
Mailing Address - Phone:617-637-5696
Mailing Address - Fax:
Practice Address - Street 1:1208B VFW PKWY STE 307
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4350
Practice Address - Country:US
Practice Address - Phone:617-325-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18596151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice