Provider Demographics
NPI:1033363395
Name:CAMBRIDGE DENTAL ANNEX
Entity Type:Organization
Organization Name:CAMBRIDGE DENTAL ANNEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:K
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-871-1482
Mailing Address - Street 1:897 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3045
Mailing Address - Country:US
Mailing Address - Phone:617-871-1482
Mailing Address - Fax:617-871-1484
Practice Address - Street 1:897 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3045
Practice Address - Country:US
Practice Address - Phone:617-871-1482
Practice Address - Fax:617-871-1484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17123261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental