Basic Information
| Provider Information | |||||||||
| NPI: | 1407410848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DVORAK | ||||||||
| FirstName: | CARRIE | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 KELTON ST APT 6 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021344373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154837996 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1493 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2019 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 4635 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.