Healthcare Provider Details

I. General information

NPI: 1376032292
Provider Name (Legal Business Name): BOSTON PARK DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128A TREMONT ST FL 3
BOSTON MA
02108-4716
US

IV. Provider business mailing address

128A TREMONT ST FL 3
BOSTON MA
02108-4716
US

V. Phone/Fax

Practice location:
  • Phone: 617-482-1117
  • Fax:
Mailing address:
  • Phone: 617-482-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YONGJEONG KIM
Title or Position: SECRETARY
Credential:
Phone: 617-482-1117