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General NPI Number Information
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NPI Number | 1780974477
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Entity Type | Organization
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Legal Business Name | MEDFORD ENDODONTICS, LLC
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Dates
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Enumeration Date | 04/14/2011
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Last Update Date | 04/14/2011
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Provider Practice Location Address
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Address Line | ZERO GOVERNORS AVENUE, SUITE 30
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City | MEDFORD
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State | MA
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Zip | 02155-3006
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Country | US
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Telephone | 781-391-5100
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Fax | 781-391-4833
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Provider Business Mailing Address
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Address Line | ZERO GOVERNORS AVENUE., SUITE 30
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City | MEDFORD
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State | MA
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Zip | 02155-0000
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Country | US
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Telephone | 781-391-5100
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK G WANG
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Credential | D.M.D.
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Telephone | 781-391-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 20514
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License Number State | MA
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