Healthcare Provider Details

I. General information

NPI: 1437232238
Provider Name (Legal Business Name): INTERNATIONAL PLACE DENTAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INTERNATIONAL PL FLOOR 7
BOSTON MA
02110-2602
US

IV. Provider business mailing address

ONE INTERNATIONAL PLACE FLOOR 7
BOSTON MA
02110
US

V. Phone/Fax

Practice location:
  • Phone: 617-330-8887
  • Fax: 617-330-8730
Mailing address:
  • Phone: 617-330-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12879
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18636
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11855
License Number StateMA

VIII. Authorized Official

Name: MS. ANDREA ELLIS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 617-330-8887