Provider Demographics
NPI:1164433215
Name:PLEASANT VALLEY DENTAL HEALTH, PC
Entity Type:Organization
Organization Name:PLEASANT VALLEY DENTAL HEALTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:WAINWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-685-2511
Mailing Address - Street 1:380 MERRIMACK ST
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5870
Mailing Address - Country:US
Mailing Address - Phone:978-685-2511
Mailing Address - Fax:978-683-3985
Practice Address - Street 1:380 MERRIMACK ST
Practice Address - Street 2:SUITE 3E
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5870
Practice Address - Country:US
Practice Address - Phone:978-685-2511
Practice Address - Fax:978-683-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147471223G0001X
MA197031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0200671Medicaid
MA9783547Medicaid