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General NPI Number Information
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NPI Number | 1093128225
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Entity Type | Organization
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Legal Business Name | MARION VILLAGE DENTAL
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Dates
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Enumeration Date | 06/05/2014
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Last Update Date | 06/05/2014
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Provider Practice Location Address
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Address Line | 54 MAIN STREET SUITE 6 C/O LAKEVILLE DENTAL
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City | LAKEVILLE
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State | MA
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Zip | 02347
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Country | US
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Telephone | 508-923-6900
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Fax |
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Provider Business Mailing Address
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Address Line | 156 FRONT ST STE 3
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City | MARION
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State | MA
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Zip | 02738-1501
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Country | US
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Telephone | 508-748-1700
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST PROVIDER
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Name | DR. CHUONG PHAM
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Credential | DMD
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Telephone | 508-748-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 20826
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License Number State | MA
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