Provider Demographics
NPI:1225725286
Name:GREATER BOSTON SMILES PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:GREATER BOSTON SMILES PEDIATRIC DENTISTRY PLLC
Other - Org Name:GREATER BOSTON SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-678-3125
Mailing Address - Street 1:240 DEVONSHIRE ST UNIT 4501
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-2172
Mailing Address - Country:US
Mailing Address - Phone:617-678-3125
Mailing Address - Fax:
Practice Address - Street 1:300 CROWN COLONY DR STE 203
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0929
Practice Address - Country:US
Practice Address - Phone:617-472-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-20
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty