Healthcare Provider Details

I. General information

NPI: 1538503099
Provider Name (Legal Business Name): TOWN CENTER ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ELISSA AVE
WAYLAND MA
01778-3154
US

IV. Provider business mailing address

21 ELISSA AVE
WAYLAND MA
01778-3154
US

V. Phone/Fax

Practice location:
  • Phone: 508-358-6300
  • Fax:
Mailing address:
  • Phone: 508-358-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number18640
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. CHUN YU YOGI CHEN
Title or Position: OWNER
Credential: DMD
Phone: 508-358-6300