Provider Demographics
NPI:1053462358
Name:SOUTH SHORE ORAL SURGERY ASSOCIATES CO. INC.
Entity Type:Organization
Organization Name:SOUTH SHORE ORAL SURGERY ASSOCIATES CO. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LUSTBADER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-773-9500
Mailing Address - Street 1:270 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8127
Mailing Address - Country:US
Mailing Address - Phone:617-773-9500
Mailing Address - Fax:617-773-2827
Practice Address - Street 1:270 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8127
Practice Address - Country:US
Practice Address - Phone:617-773-9500
Practice Address - Fax:617-773-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT96079Medicare UPIN
X10456Medicare ID - Type Unspecified
X10457Medicare ID - Type Unspecified