Provider Demographics
NPI:1104399443
Name:RELIANT DENTAL GROUP PC
Entity Type:Organization
Organization Name:RELIANT DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THIAGO
Authorized Official - Middle Name:
Authorized Official - Last Name:SOARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-250-6936
Mailing Address - Street 1:1996 CENTRE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3330
Mailing Address - Country:US
Mailing Address - Phone:617-221-8000
Mailing Address - Fax:617-531-2081
Practice Address - Street 1:1996 CENTRE ST STE 201
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-3330
Practice Address - Country:US
Practice Address - Phone:617-221-8000
Practice Address - Fax:617-531-2081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RELIANT DENTAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty