Provider Demographics
NPI:1275665705
Name:NORTHGATE DENTAL CENTER, PC
Entity Type:Organization
Organization Name:NORTHGATE DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAVE-VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-747-0400
Mailing Address - Street 1:PO BOX 2218
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01101-2218
Mailing Address - Country:US
Mailing Address - Phone:413-747-0400
Mailing Address - Fax:413-747-2440
Practice Address - Street 1:1985 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1072
Practice Address - Country:US
Practice Address - Phone:413-747-0400
Practice Address - Fax:413-747-2440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA181001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9753371Medicaid