Healthcare Provider Details

I. General information

NPI: 1053890780
Provider Name (Legal Business Name): NEWBURYPORT DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INN ST APT 4
NEWBURYPORT MA
01950-2557
US

IV. Provider business mailing address

500 CHAPMAN ST UNIT 201
CANTON MA
02021-2040
US

V. Phone/Fax

Practice location:
  • Phone: 978-462-2530
  • Fax:
Mailing address:
  • Phone: 781-562-0457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: RICHARD TODD MILLER
Title or Position: PRESIDENT
Credential: DMD
Phone: 781-562-0457