Provider Demographics
NPI:1215574694
Name:NISTAR PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:NISTAR PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAHNAAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:NISTAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-892-3625
Mailing Address - Street 1:45 OWENCROFT RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4723
Mailing Address - Country:US
Mailing Address - Phone:917-892-3625
Mailing Address - Fax:
Practice Address - Street 1:76 MERRIMACK ST STE 8A
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6246
Practice Address - Country:US
Practice Address - Phone:917-892-3625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1952610008Medicaid