Provider Demographics
NPI:1073664819
Name:JP FAMILY DENTAL PC
Entity Type:Organization
Organization Name:JP FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-524-5400
Mailing Address - Street 1:315 CENTRE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1414
Mailing Address - Country:US
Mailing Address - Phone:617-524-5400
Mailing Address - Fax:
Practice Address - Street 1:315 CENTRE ST STE 3
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1414
Practice Address - Country:US
Practice Address - Phone:617-524-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203980Medicaid