Provider Demographics
NPI:1487613980
Name:VIDAL, MIGUEL D (DMD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:D
Last Name:VIDAL
Suffix:
Gender:M
Credentials:DMD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT STREET CPZ 401
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-1076
Practice Address - Fax:617-724-6681
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2022-07-21
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Provider Licenses
StateLicense IDTaxonomies
MA20890204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63959Medicare UPIN