Healthcare Provider Details

I. General information

NPI: 1073241469
Provider Name (Legal Business Name): LYNNFIELD PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 KIMBALL LN STE 140
LYNNFIELD MA
01940-2667
US

IV. Provider business mailing address

9 MONTAGUE ST UNIT C
CAMBRIDGE MA
02139-3721
US

V. Phone/Fax

Practice location:
  • Phone: 617-895-6700
  • Fax:
Mailing address:
  • Phone: 617-895-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HUBERT J PARK
Title or Position: PRESIDENT
Credential: DMD, MPH
Phone: 617-895-6700