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Provider Information for 1760603401

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1760603401

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1760603401
Enumeration Date 2007-05-01
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 41 DEAN ST
SOUTH EASTON, MA 02375-1433
United States

Phone: | Fax:
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Primary Practice Address 966C PARK ST
STOUGHTON, MA 02072-3650
United States

Phone: 781-341-0030 | Fax: 781-341-1166
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223P0221X - Dentist Pediatric Dentistry MA 20896