Provider Demographics
NPI: | 1295217065 |
---|---|
Name: | WESTERN MASS PERIODONTICS PC |
Entity Type: | Organization |
Organization Name: | WESTERN MASS PERIODONTICS PC |
Other - Org Name: | AKRAM E. RAFLA DMD, PC |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | CREDENTIALING ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LEAH |
Authorized Official - Middle Name: | ANN |
Authorized Official - Last Name: | MAYLOTT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 860-874-8198 |
Mailing Address - Street 1: | 65 ELM ST |
Mailing Address - Street 2: | |
Mailing Address - City: | WORCESTER |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 01609-2547 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-874-8198 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 65 ELM ST |
Practice Address - Street 2: | |
Practice Address - City: | WORCESTER |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01609-2547 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-363-4400 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | WESTERN MASS PERIODONTICS PC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2018-08-29 |
Last Update Date: | 2022-08-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0300X | Dental Providers | Dentist | Periodontics | Group - Single Specialty |