1003579277 NPI number — CEDAR BROOK PEDIATRIC DENTISTRY PLLC

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 1003579277 NPI number — CEDAR BROOK PEDIATRIC DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR BROOK PEDIATRIC DENTISTRY PLLC
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:
1003579277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 BAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01532-3403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 CORDAVILLE RD STE 175
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01772-1838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-817-6346
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LA
Authorized Official First Name:
NAOMI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE OWNER
Authorized Official Telephone Number:
617-817-6346

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com