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General NPI Number Information
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NPI Number | 1063732477
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Entity Type | Organization
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Legal Business Name | CONCORDDENTAL IMPLANTS &PERIODONTICS
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Dates
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Enumeration Date | 06/08/2010
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Last Update Date | 06/08/2010
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Provider Practice Location Address
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Address Line | 290 BAKER AVE S205
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City | CONCORD
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State | MA
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Zip | 01742-2189
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Country | US
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Telephone | 978-369-4611
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Fax | 978-369-4622
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Provider Business Mailing Address
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Address Line | 290 BAKER AVE SUITE205
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City | CONCORD
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State | MA
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Zip | 01742-2189
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Country | US
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Telephone | 978-369-4611
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Fax | 978-369-4622
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK Y. WANG
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Credential | DMD
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Telephone | 978-369-4611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 18710
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License Number State | MA
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