Healthcare Provider Details

I. General information

NPI: 1134456346
Provider Name (Legal Business Name): BROOKLINE DENTURE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 BEACON ST
BROOKLINE MA
02445-1930
US

IV. Provider business mailing address

1842 BEACON ST
BROOKLINE MA
02445-1930
US

V. Phone/Fax

Practice location:
  • Phone: 617-738-1232
  • Fax: 617-730-8482
Mailing address:
  • Phone: 617-738-1232
  • Fax: 617-730-8482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17049
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18964
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10426
License Number StateMA

VIII. Authorized Official

Name: DR. BERDJ KILADJIAN
Title or Position: RESIDENT AGENT
Credential: D.M.D
Phone: 617-738-1232