Basic Information
| Provider Information | |||||||||
| NPI: | 1427484062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE PEDIATRIC DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 FEDERAL ST | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021882108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813405437 | ||||||||
| FaxNumber: | 7813405438 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 FEDERAL ST | ||||||||
| Address2: | |||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021882108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813405437 | ||||||||
| FaxNumber: | 7813405438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2013 | ||||||||
| LastUpdateDate: | 09/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUA | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
| AuthorizedOfficialMiddleName: | SANGGUOT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7813405437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DN1855205 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.