Healthcare Provider Details

I. General information

NPI: 1255411831
Provider Name (Legal Business Name): DENTAL ASSOCIATES OF WALPOLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 MAIN ST SUITE 1
WALPOLE MA
02081-1729
US

IV. Provider business mailing address

1428 MAIN ST SUITE 1
WALPOLE MA
02081-1729
US

V. Phone/Fax

Practice location:
  • Phone: 508-668-8008
  • Fax: 508-668-8808
Mailing address:
  • Phone: 508-668-8008
  • Fax: 508-668-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11377
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12246
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12607
License Number StateMA

VIII. Authorized Official

Name: DR. CHRISTOPHER RUSSELL PAGE
Title or Position: PARTNER/OWNER
Credential: DMD
Phone: 508-668-8008