Healthcare Provider Details

I. General information

NPI: 1639654064
Provider Name (Legal Business Name): CHICOPEE DENTISTRY AND BRACES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 MEMORIAL DR
CHICOPEE MA
01020-5024
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 413-331-2124
  • Fax: 413-650-5829
Mailing address:
  • Phone: 508-872-3072
  • Fax: 508-872-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524