Healthcare Provider Details

I. General information

NPI: 1841766433
Provider Name (Legal Business Name): MARLBOROUGH DENTAL SPECIALTIES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAIN ST STE 2
MARLBOROUGH MA
01752-3811
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 774-374-2327
  • Fax: 774-374-2328
Mailing address:
  • Phone: 508-872-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MS. JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524