1023140498 NPI number — COMMONWEALTH OF MASSACHUSETTS-DDS

Table of content: (NPI 1023140498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023140498 NPI number — COMMONWEALTH OF MASSACHUSETTS-DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF MASSACHUSETTS-DDS
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:
6
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:
1023140498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 HARRISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-727-5608
Provider Business Mailing Address Fax Number:
617-624-7577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 MAIN ST
Provider Second Line Business Practice Location Address:
THIRD FLOOR
Provider Business Practice Location Address City Name:
S WEYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02190-1561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-337-2165
Provider Business Practice Location Address Fax Number:
781-337-2179
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAILLET
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR REVENUE MANAGER
Authorized Official Telephone Number:
617-727-5608

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  EXEMPT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1802909 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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