Healthcare Provider Details

I. General information

NPI: 1972999233
Provider Name (Legal Business Name): BOSTON DENTAL RESTORATIVE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 NEW CHARDON ST SUITE 102
BOSTON MA
02114-4774
US

IV. Provider business mailing address

25 NEW CHARDON ST SUITE 102
BOSTON MA
02114-4774
US

V. Phone/Fax

Practice location:
  • Phone: 617-227-4924
  • Fax: 617-227-1824
Mailing address:
  • Phone: 617-227-4924
  • Fax: 617-227-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEXANDER RENE SCHROTT
Title or Position: MANAGING DIRECTOR
Credential: DMD, MMSC
Phone: 617-227-4924