Provider Demographics
NPI:1326417569
Name:SEAPORT DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SEAPORT DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:GREENBERG
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-737-6453
Mailing Address - Street 1:451 D ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1964
Mailing Address - Country:US
Mailing Address - Phone:617-737-6453
Mailing Address - Fax:617-737-6324
Practice Address - Street 1:588 RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-4524
Practice Address - Country:US
Practice Address - Phone:617-737-6453
Practice Address - Fax:617-737-6324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEAPORT DENTAL ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-17
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty