Provider Demographics
NPI:1194215160
Name:SOCIAL STREET DENTAL
Entity Type:Organization
Organization Name:SOCIAL STREET DENTAL
Other - Org Name:SOCIAL STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEFA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-921-1575
Mailing Address - Street 1:515 SOCIAL ST
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-2043
Mailing Address - Country:US
Mailing Address - Phone:401-597-5920
Mailing Address - Fax:401-597-5924
Practice Address - Street 1:515 SOCIAL ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-2043
Practice Address - Country:US
Practice Address - Phone:401-597-5920
Practice Address - Fax:401-597-5924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN026371223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI=========OtherPRIVATE INSURANCE