Healthcare Provider Details

I. General information

NPI: 1467085407
Provider Name (Legal Business Name): WESTERN MASS PERIODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 01/18/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W AVON RD STE 101
AVON CT
06001-3677
US

IV. Provider business mailing address

65 ELM ST
WORCESTER MA
01609-2547
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-0451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: LEAH ANN MAYLOTT
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 860-874-8198