Provider Demographics
NPI:1083278378
Name:CENTER FOR DENTAL MEDICINE & RECONSTRUCTION
Entity Type:Organization
Organization Name:CENTER FOR DENTAL MEDICINE & RECONSTRUCTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-728-5455
Mailing Address - Street 1:32 TRAVELER ST UNIT 510
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2840
Mailing Address - Country:US
Mailing Address - Phone:617-851-5463
Mailing Address - Fax:
Practice Address - Street 1:152 LINCOLN RD STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:MA
Practice Address - Zip Code:01773-3832
Practice Address - Country:US
Practice Address - Phone:781-728-5455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1821365479Medicaid
MA1669663886Medicaid