=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225915770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER BOSTON ORAL SURGERY AND DENTAL IMPLANT CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2025
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 MAIN ST STE 201
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-875-7827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 MAIN ST STE 201
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-875-7827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | CHAD HENDRICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-859-0444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------