Provider Demographics
NPI:1356648075
Name:ADVANCED DENTAL SPA OF FALL RIVER LLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL SPA OF FALL RIVER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAED
Authorized Official - Middle Name:
Authorized Official - Last Name:YAZBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-567-4544
Mailing Address - Street 1:373 NEW BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5814
Mailing Address - Country:US
Mailing Address - Phone:508-567-4544
Mailing Address - Fax:
Practice Address - Street 1:373 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5814
Practice Address - Country:US
Practice Address - Phone:508-567-4544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL SPA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222521223G0001X
MA216571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty