Provider Demographics
NPI:1346463973
Name:NANETTE DEMONTEVERDE, DMD, PC
Entity Type:Organization
Organization Name:NANETTE DEMONTEVERDE, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANETTE
Authorized Official - Middle Name:CANERO
Authorized Official - Last Name:DEMONTEVERDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-391-2440
Mailing Address - Street 1:30 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-7112
Mailing Address - Country:US
Mailing Address - Phone:781-391-2440
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-7112
Practice Address - Country:US
Practice Address - Phone:781-391-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9708791Medicaid