MEDICARE: COMMUNITY DENTAL PC

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	122300000X	Dentist
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1932790789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY DENTAL PC

Provider Business Mailing Address
First Line	:	1 ELM AVE
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-2923
Country	:	US
Telephone Number	:	617-291-8838
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 ELM AVE
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-2923
Country	:	US
Telephone Number	:	617-472-7499
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BEN LIU
Credential	:	DMD
Telephone Number	:	617-291-8838

Provider Enumeration Date	:	02/02/2021
Last Update Date	:	02/02/2021

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