Healthcare Provider Details

I. General information

NPI: 1679747398
Provider Name (Legal Business Name): BAY STATE ORAL SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LINDEN STREET
WORCESTER MA
01609
US

IV. Provider business mailing address

9 LINDEN STREET
WORCESTER MA
01609
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-0008
  • Fax: 508-770-0603
Mailing address:
  • Phone: 508-755-0008
  • Fax: 508-770-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10436
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21007
License Number StateMA

VIII. Authorized Official

Name: XUE YU SHEN
Title or Position: PRESIDENT
Credential: DMD
Phone: 508-755-0008