Provider Demographics
NPI:1093128225
Name:MARION VILLAGE DENTAL
Entity Type:Organization
Organization Name:MARION VILLAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-748-1700
Mailing Address - Street 1:156 FRONT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MA
Mailing Address - Zip Code:02738-1501
Mailing Address - Country:US
Mailing Address - Phone:508-748-1700
Mailing Address - Fax:
Practice Address - Street 1:54 MAIN STREET
Practice Address - Street 2:SUITE 6 C/O LAKEVILLE DENTAL
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347
Practice Address - Country:US
Practice Address - Phone:508-923-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20826261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental