Provider Demographics
NPI:1346496031
Name:ANDOVER COSMETIC DENTAL GROUP
Entity Type:Organization
Organization Name:ANDOVER COSMETIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-562-3442
Mailing Address - Street 1:34 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3064
Mailing Address - Country:US
Mailing Address - Phone:978-475-9111
Mailing Address - Fax:978-475-6661
Practice Address - Street 1:34 PARK STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3064
Practice Address - Country:US
Practice Address - Phone:978-475-9111
Practice Address - Fax:978-475-6661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty