Healthcare Provider Details

I. General information

NPI: 1245402577
Provider Name (Legal Business Name): WORCESTER PEDIATRIC DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 PLEASANT ST
WORCESTER MA
01609-3208
US

IV. Provider business mailing address

144 PLEASANT ST
WORCESTER MA
01609-3208
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-9825
  • Fax: 508-754-9898
Mailing address:
  • Phone: 508-754-9825
  • Fax: 508-754-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number21437
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. CHENGETO M. VERA
Title or Position: MEMBER
Credential: DMD, MPH
Phone: 508-754-9825