Healthcare Provider Details

I. General information

NPI: 1528644879
Provider Name (Legal Business Name): WORCESTER DENTISTRY AND BRACES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 SOUTHBRIDGE ST STE 1
WORCESTER MA
01610-1757
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 508-492-3300
  • Fax: 508-492-3301
Mailing address:
  • Phone: 508-492-3300
  • Fax: 508-492-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524