Provider Demographics
NPI:1114340122
Name:WINCHESTER FAMILY DENTAL
Entity Type:Organization
Organization Name:WINCHESTER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-694-1614
Mailing Address - Street 1:831 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1997
Mailing Address - Country:US
Mailing Address - Phone:617-694-1614
Mailing Address - Fax:
Practice Address - Street 1:831 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1997
Practice Address - Country:US
Practice Address - Phone:617-694-1614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROADWAY DENTIST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0205150OtherMASS HEALTH ID 0205150