Provider Demographics
NPI:1104243674
Name:WINTER STREET DENTAL GROUP
Entity type:Organization
Organization Name:WINTER STREET DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHAZWAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GHAZI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:508-771-3887
Mailing Address - Street 1:188 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-2958
Mailing Address - Country:US
Mailing Address - Phone:508-771-3887
Mailing Address - Fax:508-778-0845
Practice Address - Street 1:188 WINTER ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2958
Practice Address - Country:US
Practice Address - Phone:508-771-3887
Practice Address - Fax:508-778-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18265261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental