Provider Demographics
NPI:1386277663
Name:AWLACHEW, SHIFERAW SR (ETC)
Entity type:Individual
Prefix:MR
First Name:SHIFERAW
Middle Name:
Last Name:AWLACHEW
Suffix:SR
Gender:M
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-2811
Mailing Address - Country:US
Mailing Address - Phone:781-300-1774
Mailing Address - Fax:
Practice Address - Street 1:14 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-2811
Practice Address - Country:US
Practice Address - Phone:781-300-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADA08481126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA451734099Medicaid