1598976516 NPI number — HIGHLAND DENTAL DMD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598976516 NPI number — HIGHLAND DENTAL DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND DENTAL DMD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598976516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
366 BROADWAY
Provider Second Line Business Mailing Address:
202
Provider Business Mailing Address City Name:
SOMERVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02145-2812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-623-7474
Provider Business Mailing Address Fax Number:
617-591-9747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
366 BROADWAY
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
SOMERVILLE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02145-2812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-623-7474
Provider Business Practice Location Address Fax Number:
617-591-9747
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHTEYNBERG
Authorized Official First Name:
ZOYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
617-623-7474

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18262 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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