Basic Information
Provider Information
NPI: 1003153305
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CABRERA
FirstName: VIANCA
MiddleName: ELIZE
NamePrefix: DR.
NameSuffix:  
Credential: D.M.D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 45 E NEWTON ST
Address2: APT 110
City: BOSTON
State: MA
PostalCode: 021184802
CountryCode: US
TelephoneNumber: 3057905857
FaxNumber:  
Practice Location
Address1: 100 E NEWTON ST
Address2: 2ND FLOOR, SUITE 217
City: BOSTON
State: MA
PostalCode: 021182308
CountryCode: US
TelephoneNumber: 6176384750
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/08/2013
LastUpdateDate: 01/08/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223P0300XDL11793MAY Dental ProvidersDentistPeriodontics
1223P0300XDN19684FLN Dental ProvidersDentistPeriodontics

No ID Information.


Home