Provider Demographics
NPI:1265823595
Name:GREAT SMILES ON THE GO
Entity Type:Organization
Organization Name:GREAT SMILES ON THE GO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCHALIDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-249-9884
Mailing Address - Street 1:98 STOW RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1538
Mailing Address - Country:US
Mailing Address - Phone:774-249-9884
Mailing Address - Fax:
Practice Address - Street 1:98 STOW RD
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1538
Practice Address - Country:US
Practice Address - Phone:774-249-9884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH87679124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty