MEDICARE: BLACKSTONE VALLEY DENTAL ASSOCIATES, LLC

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	1223G0001X	General Practice Dentistry	19827	MA
2	1223G0001X	General Practice Dentistry	16536	MA

General Provider Information

NPI Number	:	1962575571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKSTONE VALLEY DENTAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	12 MAIN ST
Second Line	:
City	:	BLACKSTONE
State	:	MA
Zip	:	01504-2202
Country	:	US
Telephone Number	:	508-883-1050
Fax Number	:	508-883-0911

Provider Business Practice Location Address
First Line	:	12 MAIN ST
Second Line	:
City	:	BLACKSTONE
State	:	MA
Zip	:	01504-2202
Country	:	US
Telephone Number	:	508-883-1050
Fax Number	:	508-883-0911

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. TODD B HARRIS
Credential	:	D.M.D
Telephone Number	:	508-883-1050

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/22/2008

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