Provider Demographics
NPI:1982907762
Name:SHAWSHEEN FAMILY DENTAL
Entity Type:Organization
Organization Name:SHAWSHEEN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTILLO-GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-851-7112
Mailing Address - Street 1:1455 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-4769
Mailing Address - Country:US
Mailing Address - Phone:978-851-7112
Mailing Address - Fax:978-851-2811
Practice Address - Street 1:1455 MAIN ST
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4769
Practice Address - Country:US
Practice Address - Phone:978-851-7112
Practice Address - Fax:978-851-2811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20116261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental