Healthcare Provider Details

I. General information

NPI: 1154658607
Provider Name (Legal Business Name): PEDIATRIC DENTAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 MAIN ST
MILFORD MA
01757
US

IV. Provider business mailing address

116 MAIN ST
MARLBOROUGH MA
01752-3811
US

V. Phone/Fax

Practice location:
  • Phone: 508-473-5437
  • Fax:
Mailing address:
  • Phone: 508-485-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number21980
License Number StateMA

VIII. Authorized Official

Name: PATRICK F ASSIOUN
Title or Position: CEO
Credential: DMD, MMSC
Phone: 508-366-7976