Provider Demographics
NPI:1003143157
Name:ST.JOSEPH'S FAMILY DENTAL,LLC
Entity Type:Organization
Organization Name:ST.JOSEPH'S FAMILY DENTAL,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:AGUERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:413-737-3181
Mailing Address - Street 1:258 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3955
Mailing Address - Country:US
Mailing Address - Phone:413-737-3181
Mailing Address - Fax:413-737-3184
Practice Address - Street 1:258 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3955
Practice Address - Country:US
Practice Address - Phone:413-737-3181
Practice Address - Fax:413-737-3184
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST.JOSEPH'S FAMILY DENTAL,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076716BMedicaid