1629567243 NPI number — MILLIS DENTAL CARE, PC

Table of content: (NPI 1083814404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629567243 NPI number — MILLIS DENTAL CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLIS DENTAL CARE, 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:
1629567243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 MAPLEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUDBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01776-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-999-7686
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MILLIS DENTAL CARE, PC
Provider Second Line Business Practice Location Address:
840 MAIN STREET, SUITE 112
Provider Business Practice Location Address City Name:
MILLIS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02054-1542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-556-0882
Provider Business Practice Location Address Fax Number:
508-376-8997
Provider Enumeration Date:
05/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GRAVELINE
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
774-241-6254

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN1856691 , 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)





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