=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477253805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON DENTAL PARTNERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 BEAR HILL RD STE 301
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-620-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 BEAR HILL RD STE 301
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-620-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ABHISHEK JAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-620-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------