Provider Demographics
NPI:1043645336
Name:ELITE DENTAL GROUP PC
Entity Type:Organization
Organization Name:ELITE DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SATHISH
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOBICHETTYPALAYAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-980-4734
Mailing Address - Street 1:523 FOUNDRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-2736
Mailing Address - Country:US
Mailing Address - Phone:508-238-4265
Mailing Address - Fax:508-230-2451
Practice Address - Street 1:523 FOUNDRY ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-2736
Practice Address - Country:US
Practice Address - Phone:508-238-4265
Practice Address - Fax:508-230-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22099261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22099OtherMA DENTAL LIC