=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942166269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLAS DENTAL CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2025
-----------------------------------------------------
Last Update Date | 12/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 HUDSON RD
-----------------------------------------------------
City | BOLTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01740-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-728-1327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 HUDSON RD
-----------------------------------------------------
City | BOLTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01740-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-728-1327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | CHAD HENDRICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-859-0444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------