Healthcare Provider Details

I. General information

NPI: 1194059725
Provider Name (Legal Business Name): METROWEST DENTAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAIN ST SUITE 1
MARLBOROUGH MA
01752-3811
US

IV. Provider business mailing address

116 MAIN ST SUITE 1
MARLBOROUGH MA
01752-3811
US

V. Phone/Fax

Practice location:
  • Phone: 508-485-2001
  • Fax: 508-485-2201
Mailing address:
  • Phone: 508-485-2001
  • Fax: 508-485-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: REGINA STJOHN
Title or Position: CREDENTIALING DEPT
Credential:
Phone: 508-460-1212