Provider Demographics
NPI:1114249778
Name:PARK DENTAL GROUP
Entity Type:Organization
Organization Name:PARK DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:RECUPERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-344-5211
Mailing Address - Street 1:480 PARK ST
Mailing Address - Street 2:P.O. BOX 360
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3085
Mailing Address - Country:US
Mailing Address - Phone:781-344-5211
Mailing Address - Fax:781-297-2049
Practice Address - Street 1:480 PARK ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-3085
Practice Address - Country:US
Practice Address - Phone:781-344-5211
Practice Address - Fax:781-297-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty