=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104040757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUSTEES OF TUFTS UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 GODDARD MEMORIAL DR STE 2
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01603-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-751-6746
-----------------------------------------------------
Fax | 508-756-3405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 GODDARD MEMORIAL DR STE 2
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01603-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-751-6746
-----------------------------------------------------
Fax | 508-756-3405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | DR. JOHN PATRICK MORGAN JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-899-6020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 20040
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------