Provider Demographics
NPI:1346013414
Name:IDG BOSTON PO SQUARE DENTAL PC
Entity Type:Organization
Organization Name:IDG BOSTON PO SQUARE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEEJEONG
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-485-4752
Mailing Address - Street 1:1996 CENTRE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3330
Mailing Address - Country:US
Mailing Address - Phone:617-221-8000
Mailing Address - Fax:617-531-2081
Practice Address - Street 1:10 POST OFFICE SQ STE 655
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4603
Practice Address - Country:US
Practice Address - Phone:617-423-6777
Practice Address - Fax:617-622-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty