1558470161 NPI number — SOUTH SHORE ENDODONTICS BRAINTREE PC

Table of content: (NPI 1558470161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558470161 NPI number — SOUTH SHORE ENDODONTICS BRAINTREE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE ENDODONTICS BRAINTREE 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:
1558470161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 FRANKLIN STREET
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BRAIN TREE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-849-3051
Provider Business Mailing Address Fax Number:
781-356-7039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 FRANKLIN STREET
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
BRAIN TREE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-849-3051
Provider Business Practice Location Address Fax Number:
781-356-7039
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STARLINE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER ENDODONTIST
Authorized Official Telephone Number:
781-849-3051

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  14725 , 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: 826203 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100402 . This is a "DELTA DENTAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: X10469 . This is a "BCBS OF MA" identifier . This identifiers is of the category "OTHER".




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