Healthcare Provider Details

I. General information

NPI: 1902074073
Provider Name (Legal Business Name): MARLBOROUGH ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 LAKESIDE AVE
MARLBOROUGH MA
01752-1979
US

IV. Provider business mailing address

431 LAKESIDE AVE
MARLBOROUGH MA
01752-1979
US

V. Phone/Fax

Practice location:
  • Phone: 508-485-5575
  • Fax:
Mailing address:
  • Phone: 508-485-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21555
License Number StateMA

VIII. Authorized Official

Name: DR. EUGER LIN
Title or Position: PRESIDENT
Credential: DMD, FRCD(C)
Phone: 508-485-5575