Provider Demographics
NPI:1316590839
Name:CELESTIAL SMILE DENTAL ASSOCIATES - MA PC
Entity Type:Organization
Organization Name:CELESTIAL SMILE DENTAL ASSOCIATES - MA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLATUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-774-9885
Mailing Address - Street 1:376 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1830
Mailing Address - Country:US
Mailing Address - Phone:781-774-9885
Mailing Address - Fax:
Practice Address - Street 1:376 WARREN ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1830
Practice Address - Country:US
Practice Address - Phone:781-774-9885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty