Provider Demographics
NPI:1063839207
Name:DEDHAM ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:DEDHAM ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, LICAC
Authorized Official - Phone:781-686-2395
Mailing Address - Street 1:111 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4515
Mailing Address - Country:US
Mailing Address - Phone:781-686-2395
Mailing Address - Fax:781-326-2277
Practice Address - Street 1:111 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4515
Practice Address - Country:US
Practice Address - Phone:781-686-2395
Practice Address - Fax:781-326-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216170171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1346685997OtherUPIN
MA1841487428OtherNPI