Basic Information
Provider Information
NPI: 1750430716
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VIVEIROS
FirstName: JOHN
MiddleName: STEVEN
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 50 WOODLAND RD
Address2:  
City: MILTON
State: MA
PostalCode: 021863606
CountryCode: US
TelephoneNumber: 6179109440
FaxNumber:  
Practice Location
Address1: 30 WARREN ST
Address2:  
City: BRIGHTON
State: MA
PostalCode: 021353602
CountryCode: US
TelephoneNumber: 6172543800
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/09/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223P0221X18729MAY Dental ProvidersDentistPediatric Dentistry

No ID Information.


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