Healthcare Provider Details

I. General information

NPI: 1093998387
Provider Name (Legal Business Name): CROMPTON PARK ORAL SURGERY AND IMPLANT ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 QUINSIGAMOND AVE
WORCESTER MA
01610-1806
US

IV. Provider business mailing address

59 QUINSIGAMOND AVE
WORCESTER MA
01610-1806
US

V. Phone/Fax

Practice location:
  • Phone: 508-799-2550
  • Fax:
Mailing address:
  • Phone: 508-799-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12222
License Number StateMA

VIII. Authorized Official

Name: W DAVID KELLY
Title or Position: MEMBER
Credential: DMD
Phone: 508-799-2550