=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407964901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIODONTOLOGY ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 BAKER AVE S103
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-369-5521
-----------------------------------------------------
Fax | 978-369-5591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 BAKER AVE S103
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-369-5521
-----------------------------------------------------
Fax | 978-369-5591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY B FREEDMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 978-369-5521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 19000
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 13998
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------