Provider Demographics
NPI:1093871469
Name:DENTAL STUDIO ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DENTAL STUDIO ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOUTET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-786-0085
Mailing Address - Street 1:302 SUFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1749
Mailing Address - Country:US
Mailing Address - Phone:413-786-0085
Mailing Address - Fax:413-786-0025
Practice Address - Street 1:302 SUFFIELD ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1749
Practice Address - Country:US
Practice Address - Phone:413-786-0085
Practice Address - Fax:413-786-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty