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General NPI Number Information
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NPI Number | 1124359773
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL
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Dates
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Enumeration Date | 01/21/2010
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Last Update Date | 01/21/2010
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Provider Practice Location Address
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Address Line | 207 UPPER MAIN ST
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City | EDGARTOWN
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State | MA
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Zip | 02539-5927
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Country | US
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Telephone | 508-939-9000
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Fax | 508-939-8537
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Provider Business Mailing Address
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Address Line | PO BOX 2135
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City | EDGARTOWN
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State | MA
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Zip | 02539-2135
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Country | US
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Telephone | 508-939-9000
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Fax | 508-939-8537
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN CLYDE HARTLEY
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Credential | DDS
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Telephone | 508-939-9000
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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 | 19314
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License Number State | MA
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