Provider Demographics
NPI:1326295163
Name:1555 ST MANAGEMENT GROUP, INC.
Entity Type:Organization
Organization Name:1555 ST MANAGEMENT GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SANJAYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THIAGARAJAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-851-5300
Mailing Address - Street 1:1555 MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-4741
Mailing Address - Country:US
Mailing Address - Phone:978-851-5300
Mailing Address - Fax:978-851-5335
Practice Address - Street 1:1555 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4741
Practice Address - Country:US
Practice Address - Phone:978-851-5300
Practice Address - Fax:978-851-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty