1154536621 NPI number — NEW ERA DENTAL

Table of content: (NPI 1154536621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154536621 NPI number — NEW ERA DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW ERA DENTAL
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:
1154536621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
1170 BEACON ST SUITE 110 BROOKLINE MA 02446
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02140-1854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-576-6566
Provider Business Mailing Address Fax Number:
617-576-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 MASSACHUSETTS AVE
Provider Second Line Business Practice Location Address:
1170 BEACON ST
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-576-6566
Provider Business Practice Location Address Fax Number:
617-576-3005
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOLI
Authorized Official First Name:
SANDHYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE OWNER GENERAL DENTIST
Authorized Official Telephone Number:
617-576-6566

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  21256 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 19257 , 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)

  • Identifier: 1871501007 . This is a "DR GOLI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1396869582 . This is a "DR. GOHAR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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