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General NPI Number Information
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NPI Number | 1083278378
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Entity Type | Organization
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Legal Business Name | CENTER FOR DENTAL MEDICINE & RECONSTRUCTION
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Dates
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Enumeration Date | 04/23/2019
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Last Update Date | 04/23/2019
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Provider Practice Location Address
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Address Line | 152 LINCOLN RD STE 1
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City | LINCOLN
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State | MA
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Zip | 01773-3832
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Country | US
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Telephone | 781-728-5455
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Fax |
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Provider Business Mailing Address
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Address Line | 32 TRAVELER ST UNIT 510
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City | BOSTON
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State | MA
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Zip | 02118-2840
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Country | US
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Telephone | 617-851-5463
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. QUINN CHAN
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Credential | DMD
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Telephone | 781-728-5455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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