Healthcare Provider Details

I. General information

NPI: 1508195140
Provider Name (Legal Business Name): 64 HIGHLAND DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 HIGHLAND STREET
WORCESTER MA
01609
US

IV. Provider business mailing address

64 HIGHLAND STREET
WORCESTER MA
01609
US

V. Phone/Fax

Practice location:
  • Phone: 508-926-8660
  • Fax: 508-426-8667
Mailing address:
  • Phone: 508-926-8660
  • Fax: 508-926-8667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20028
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MILLER
Title or Position: OWNER
Credential: DDS
Phone: 508-926-8660