Provider Demographics
NPI:1033233713
Name:LONGWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:LONGWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERDJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KILADJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-566-5445
Mailing Address - Street 1:1842 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-1930
Mailing Address - Country:US
Mailing Address - Phone:617-566-5445
Mailing Address - Fax:617-730-8482
Practice Address - Street 1:1842 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-1930
Practice Address - Country:US
Practice Address - Phone:617-566-5445
Practice Address - Fax:617-730-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122300000X, 1223E0200X, 1223P0106X, 1223P0300X, 124Q00000X, 126800000X, 126900000X
1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Not Answered126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Not Answered126900000XDental ProvidersDental Laboratory TechnicianGroup - Multi-Specialty