Healthcare Provider Details

I. General information

NPI: 1760755417
Provider Name (Legal Business Name): ADVANCED DENTAL PROFESSIONALS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 BROADWAY STE 101
METHUEN MA
01844
US

IV. Provider business mailing address

413 BROADWAY STE101
METHUEN MA
01844
US

V. Phone/Fax

Practice location:
  • Phone: 978-258-3252
  • Fax:
Mailing address:
  • Phone: 978-258-3252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number16356
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RANDALL L DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 978-258-3252