Healthcare Provider Details

I. General information

NPI: 1023425808
Provider Name (Legal Business Name): COMMONWEALTH PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ELM ST
WORCESTER MA
01609-2541
US

IV. Provider business mailing address

48 ELM ST
WORCESTER MA
01609-2541
US

V. Phone/Fax

Practice location:
  • Phone: 150-875-4122
  • Fax: 508-754-9378
Mailing address:
  • Phone: 150-875-4122
  • Fax: 508-754-9378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20952
License Number StateMA

VIII. Authorized Official

Name: SUSAN MARIE DEPATIE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 508-754-1122