Provider Demographics
NPI:1083907406
Name:DR. DENTAL OF METHUEN, PC
Entity Type:Organization
Organization Name:DR. DENTAL OF METHUEN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:INCOLLINGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-887-2100
Mailing Address - Street 1:162 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-3462
Mailing Address - Country:US
Mailing Address - Phone:617-887-2100
Mailing Address - Fax:617-887-2102
Practice Address - Street 1:162 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-3462
Practice Address - Country:US
Practice Address - Phone:617-887-2100
Practice Address - Fax:617-887-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20485261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9794395Medicaid