Provider Demographics
NPI:1235599333
Name:MCM DENTAL, LLC
Entity Type:Organization
Organization Name:MCM DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAXWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-235-0121
Mailing Address - Street 1:74 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-5119
Mailing Address - Country:US
Mailing Address - Phone:203-235-0121
Mailing Address - Fax:203-235-6337
Practice Address - Street 1:74 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CT
Practice Address - Zip Code:06451
Practice Address - Country:US
Practice Address - Phone:203-235-0121
Practice Address - Fax:203-235-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty