MEDICARE: HANOVER PEDIATRIC DENTISTRY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	1855698	MA

General Provider Information

NPI Number	:	1902313570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HANOVER PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	648 WASHINGTON ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-2386
Country	:	US
Telephone Number	:	781-312-0444
Fax Number	:

Provider Business Practice Location Address
First Line	:	648 WASHINGTON ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-2386
Country	:	US
Telephone Number	:	781-312-0444
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PEDIATRIC DENTIST
Name	:	DR. TARA LINDHOLM GROFF
Credential	:	DMD, MS
Telephone Number	:	781-312-0444

Provider Enumeration Date	:	01/04/2018
Last Update Date	:	01/04/2018

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