Provider Demographics
NPI:1114136504
Name:DISTINCTIVE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:DISTINCTIVE DENTAL ASSOCIATES
Other - Org Name:DR.'S WAXMAN AND GIORDANO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-792-9010
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:SUITE 904
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1953
Mailing Address - Country:US
Mailing Address - Phone:508-792-9010
Mailing Address - Fax:508-754-7856
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 904
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:508-792-9010
Practice Address - Fax:508-754-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty