Provider Demographics
NPI:1124595111
Name:BESPOKE DENTAL BOSTON
Entity Type:Organization
Organization Name:BESPOKE DENTAL BOSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALABAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-466-6688
Mailing Address - Street 1:48 SAINT GERMAIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 NEWBURY ST FL 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3138
Practice Address - Country:US
Practice Address - Phone:617-466-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-28
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental