Healthcare Provider Details

I. General information

NPI: 1154758084
Provider Name (Legal Business Name): COPPE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MUZZEY ST SUITE 6
LEXINGTON MA
02421-5256
US

IV. Provider business mailing address

19 MUZZEY STREET SUITE 6
LEXINGTON MA
02421
US

V. Phone/Fax

Practice location:
  • Phone: 781-861-6120
  • Fax:
Mailing address:
  • Phone: 781-861-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number11347
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number11347
License Number StateMA

VIII. Authorized Official

Name: CAROLYN COPPE
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 781-861-6120