Provider Demographics
NPI:1033691464
Name:THE TRAVELING TOOTHFAIRY, LLC
Entity Type:Organization
Organization Name:THE TRAVELING TOOTHFAIRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, BS
Authorized Official - Phone:508-596-3506
Mailing Address - Street 1:9 FIRE ROAD 15A
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462
Mailing Address - Country:US
Mailing Address - Phone:508-596-3506
Mailing Address - Fax:
Practice Address - Street 1:9 FIRE ROAD 15A
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462
Practice Address - Country:US
Practice Address - Phone:508-596-3506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-01
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10543261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental