Provider Demographics
NPI:1063109619
Name:GABRIEL, DIANDRA FILOMENA (DO)
Entity type:Individual
Prefix:
First Name:DIANDRA
Middle Name:FILOMENA
Last Name:GABRIEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1022
Mailing Address - Country:US
Mailing Address - Phone:857-316-5544
Mailing Address - Fax:
Practice Address - Street 1:632 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-3213
Practice Address - Country:US
Practice Address - Phone:617-825-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL15601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty