| NPI | 1629567243 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RENEE GRAVELINE Credentialing Specialist 774-241-6254 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856691) |
| Enumeration Date | 2018-05-09 |
| Last Update Date | 2018-05-09 |