Provider Demographics
NPI:1225574577
Name:STONEHAM PEDIATRIC DENTAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:STONEHAM PEDIATRIC DENTAL ASSOCIATES, PC
Other - Org Name:DR. MICKEY'S PEDIATRIC AND ORTHODONTIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PUSHPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-919-2273
Mailing Address - Street 1:67 MONTVALE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3618
Mailing Address - Country:US
Mailing Address - Phone:781-279-2400
Mailing Address - Fax:781-279-4640
Practice Address - Street 1:67 MONTVALE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3618
Practice Address - Country:US
Practice Address - Phone:781-279-2400
Practice Address - Fax:781-279-4640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855141122300000X, 1223P0221X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty