Healthcare Provider Details

I. General information

NPI: 1669767117
Provider Name (Legal Business Name): PEDIATRIC DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAIN ST SUITE1
MARLBOROUGH MA
01752-3811
US

IV. Provider business mailing address

116 MAIN ST SUITE1
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 TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12581
License Number StateMA

VIII. Authorized Official

Name: PATRICK ASSIOUN
Title or Position: CEO
Credential:
Phone: 978-580-1524