1811677511 NPI number — FAMILY DENTAL AND IMPLANT CENTER PC

Table of content: (NPI 1811677511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811677511 NPI number — FAMILY DENTAL AND IMPLANT CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY DENTAL AND IMPLANT CENTER 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:
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:
1811677511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 HOWLAND ST UNIT 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-4998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-335-2408
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 COUNTY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANSON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02341-1668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-294-8022
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-375-7176

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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