Provider Demographics
NPI:1255308227
Name:BRIGHAM & WOMENS HOSPITAL
Entity Type:Organization
Organization Name:BRIGHAM & WOMENS HOSPITAL
Other - Org Name:BRIGHAM DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENOIR VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESHAIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-732-7899
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-732-6974
Mailing Address - Fax:617-232-8970
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-6974
Practice Address - Fax:617-232-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2020-08-22
Deactivation Date:2006-08-16
Deactivation Code:
Reactivation Date:2007-06-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1201514Medicaid
MA1201514Medicaid