Provider Demographics
NPI:1205868098
Name:42 NORTH DENTAL CARE, LLC
Entity Type:Organization
Organization Name:42 NORTH DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:SCIALABBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-512-2709
Mailing Address - Street 1:200 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8779
Mailing Address - Country:US
Mailing Address - Phone:781-647-0772
Mailing Address - Fax:781-647-1086
Practice Address - Street 1:200 5TH AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-8779
Practice Address - Country:US
Practice Address - Phone:781-647-0772
Practice Address - Fax:781-647-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13328122300000X
1223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223P0700X, 1223X0400X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty