Provider Demographics
NPI:1225441843
Name:THE PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:THE PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ASISOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-473-5437
Mailing Address - Street 1:297 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-6337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:297 UNION AVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6337
Practice Address - Country:US
Practice Address - Phone:617-308-5361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PEDIATRIC DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA20209305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service