Healthcare Provider Details

I. General information

NPI: 1396112637
Provider Name (Legal Business Name): DENTAL RESTORATIVE GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 MASSACHUSETTS AVE
CAMBRIDGE MA
02140-1228
US

IV. Provider business mailing address

385 CONCORD AVE SUITE 100
BELMONT MA
02478-3083
US

V. Phone/Fax

Practice location:
  • Phone: 617-492-5081
  • Fax:
Mailing address:
  • Phone: 617-489-1470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN H CHANG
Title or Position: PRESIDENT
Credential: DMD
Phone: 617-489-1470