Healthcare Provider Details

I. General information

NPI: 1689391567
Provider Name (Legal Business Name): SUPER DENTAL OF WORCESTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 RUSSELL ST
WORCESTER MA
01602-2126
US

IV. Provider business mailing address

227 RUSSELL ST
WORCESTER MA
01602-2126
US

V. Phone/Fax

Practice location:
  • Phone: 508-589-8270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: AIMEE HODGERNEY
Title or Position: CREDENTIALING
Credential:
Phone: 508-589-8270