1588794499 NPI number — DR. ANDRE EUGENE ST GERMAIN DMD MSCD

Table of content: DR. ANDRE EUGENE ST GERMAIN DMD MSCD (NPI 1588794499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588794499 NPI number — DR. ANDRE EUGENE ST GERMAIN DMD MSCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST GERMAIN
Provider First Name:
ANDRE
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD MSCD
Provider Gender Code:
M

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:
1588794499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 151
Provider Second Line Business Mailing Address:
30 FRANKLIN TERRACE
Provider Business Mailing Address City Name:
VINEYARD HAVEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02568-0151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-693-0307
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EMERALD ST
Provider Second Line Business Practice Location Address:
TUFTS DENTAL FACILITY AT WRENTHAM
Provider Business Practice Location Address City Name:
WRENTHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02093-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-384-8987
Provider Business Practice Location Address Fax Number:
508-384-6594
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN106081 , 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: DN106081 . This is a "MASS DENTAL LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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