Provider Demographics
NPI:1285170142
Name:PEDIATRIC DENTAL OF MILLIS LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL OF MILLIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NADIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAB SHAMARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-376-1116
Mailing Address - Street 1:1098 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1473
Mailing Address - Country:US
Mailing Address - Phone:508-376-1116
Mailing Address - Fax:
Practice Address - Street 1:1098 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1473
Practice Address - Country:US
Practice Address - Phone:508-376-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty