Healthcare Provider Details

I. General information

NPI: 1629231709
Provider Name (Legal Business Name): GROTON DENTAL WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 MAIN STREET
GROTON MA
01450
US

IV. Provider business mailing address

495 MAIN STREET
GROTON MA
01450
US

V. Phone/Fax

Practice location:
  • Phone: 978-449-9919
  • Fax: 978-449-9929
Mailing address:
  • Phone: 978-449-9919
  • Fax: 978-449-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEAN M NORDIN-EVANS
Title or Position: OWNER
Credential: DDS
Phone: 978-449-9919