Provider Demographics
NPI:1245402577
Name:WORCESTER PEDIATRIC DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WORCESTER PEDIATRIC DENTAL GROUP LLC
Other - Org Name:WORCESTER KIDS' DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHENGETO
Authorized Official - Middle Name:M
Authorized Official - Last Name:VERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:508-754-9825
Mailing Address - Street 1:144 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-3208
Mailing Address - Country:US
Mailing Address - Phone:508-754-9825
Mailing Address - Fax:508-754-9898
Practice Address - Street 1:144 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-3208
Practice Address - Country:US
Practice Address - Phone:508-754-9825
Practice Address - Fax:508-754-9898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty