=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073241469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYNNFIELD PEDIATRIC DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2022
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 KIMBALL LN STE 140
-----------------------------------------------------
City | LYNNFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01940-2667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-895-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 MONTAGUE ST UNIT C
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-895-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HUBERT J PARK
-----------------------------------------------------
Credential | DMD, MPH
-----------------------------------------------------
Telephone | 617-895-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------