=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356110472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL MASS DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2023
-----------------------------------------------------
Last Update Date | 12/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 W BROADWAY
-----------------------------------------------------
City | GARDNER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01440-3480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-410-9664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 WESTFORD HILLS RD
-----------------------------------------------------
City | WESTFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01886-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. YOON HWAN EDWARD JEONG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 978-914-2645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------