Provider Demographics
NPI:1003060575
Name:DESJARDINS MANAGEMENT INC.
Entity Type:Organization
Organization Name:DESJARDINS MANAGEMENT INC.
Other - Org Name:COMMUNITY DENTISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILIAN
Authorized Official - Middle Name:CORALIA
Authorized Official - Last Name:DESJARDINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-459-4949
Mailing Address - Street 1:1484 GORHAM ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-5241
Mailing Address - Country:US
Mailing Address - Phone:978-459-4949
Mailing Address - Fax:978-453-2828
Practice Address - Street 1:1484 GORHAM ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-5241
Practice Address - Country:US
Practice Address - Phone:978-459-4949
Practice Address - Fax:978-453-2828
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESJARDINS MANAGEMNT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9752170Medicaid