1629528674 NPI number — SPRINGFIELD DENTISTRY AND BRACES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629528674 NPI number — SPRINGFIELD DENTISTRY AND BRACES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELD DENTISTRY AND BRACES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629528674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MOUNT ROYAL AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01752-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-460-0632
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 ARMORY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01104-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-460-0632
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TAVANO
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
978-580-1524

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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