Healthcare Provider Details

I. General information

NPI: 1730737545
Provider Name (Legal Business Name): SOUTHWOODS BOULEVARD DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SOUTHWOODS BLVD STE 1
ALBANY NY
12211-2526
US

IV. Provider business mailing address

330 WHITNEY AVE STE 740
HOLYOKE MA
01040-2789
US

V. Phone/Fax

Practice location:
  • Phone: 518-445-2505
  • Fax:
Mailing address:
  • Phone: 413-382-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEAH ANN MAYLOTT
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 860-874-8198