Healthcare Provider Details

I. General information

NPI: 1982999439
Provider Name (Legal Business Name): PEDIATRIC DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 POND ST SUITE 304
FRANKLIN MA
02038-3807
US

IV. Provider business mailing address

38 POND ST SUITE 304
FRANKLIN MA
02038-3807
US

V. Phone/Fax

Practice location:
  • Phone: 508-528-0400
  • Fax: 508-463-9999
Mailing address:
  • Phone: 508-528-0400
  • Fax: 508-463-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number21546
License Number StateMA

VIII. Authorized Official

Name: PATRICK ASSIOUN
Title or Position: CEO
Credential: DMD
Phone: 978-580-1524