Provider Demographics
NPI:1184849986
Name:BAYSTATE FAMILY DENTAL
Entity Type:Organization
Organization Name:BAYSTATE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:E
Authorized Official - Last Name:NASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:508-792-6807
Mailing Address - Street 1:9 HALMSTAD ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1519
Mailing Address - Country:US
Mailing Address - Phone:508-792-6807
Mailing Address - Fax:508-792-6804
Practice Address - Street 1:9 HALMSTAD ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1519
Practice Address - Country:US
Practice Address - Phone:508-792-6807
Practice Address - Fax:508-792-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA250859743Medicaid