Provider Demographics
NPI:1225546567
Name:PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-589-8270
Mailing Address - Street 1:87 ELM ST STE 302
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748-1638
Mailing Address - Country:US
Mailing Address - Phone:508-589-8270
Mailing Address - Fax:
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:508-589-8270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 1223P0221X
CT0113181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty