Provider Demographics
NPI:1033294368
Name:NOPSARAN CHAIMATTAYOMPOL, DMD, PC
Entity Type:Organization
Organization Name:NOPSARAN CHAIMATTAYOMPOL, DMD, PC
Other - Org Name:CROWN DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NOPSARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAIMATTAYOMPOL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-328-0693
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE#3E
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-328-0693
Mailing Address - Fax:617-328-0694
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE#3E
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-328-0693
Practice Address - Fax:617-328-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198211223G0001X
MA116931223G0001X
MA207891223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty