Healthcare Provider Details

I. General information

NPI: 1083278378
Provider Name (Legal Business Name): CENTER FOR DENTAL MEDICINE & RECONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 LINCOLN RD STE 1
LINCOLN MA
01773-3832
US

IV. Provider business mailing address

32 TRAVELER ST UNIT 510
BOSTON MA
02118-2840
US

V. Phone/Fax

Practice location:
  • Phone: 781-728-5455
  • Fax:
Mailing address:
  • Phone: 617-851-5463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. QUINN CHAN
Title or Position: OWNER/MANAGER
Credential: DMD
Phone: 781-728-5455