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General NPI Number Information
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NPI Number | 1265164081
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Entity Type | Organization
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Legal Business Name | NEDG - BACK BAY PLLC
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Dates
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Enumeration Date | 06/29/2022
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 811 BOYLSTON ST STE 3
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City | BOSTON
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State | MA
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Zip | 02116-2679
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Country | US
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Telephone | 617-267-3993
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Fax |
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Provider Business Mailing Address
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Address Line | 257 TURNPIKE RD STE 110
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City | SOUTHBOROUGH
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State | MA
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Zip | 01772-1791
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Country | US
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Telephone | 508-281-6464
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Fax |
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Authorized Official
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Title or Position | CLINICAL SYSTEMS DIRECTOR
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Name | ALICIA LACLAIR
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Credential |
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Telephone | 508-281-6464
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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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