Provider Demographics
NPI:1407052830
Name:EVERETT CHILDRENS' DENTAL CENTER PC
Entity Type:Organization
Organization Name:EVERETT CHILDRENS' DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:THACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-389-2112
Mailing Address - Street 1:186 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5222
Mailing Address - Country:US
Mailing Address - Phone:617-389-2112
Mailing Address - Fax:617-389-5885
Practice Address - Street 1:186 ELM ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5222
Practice Address - Country:US
Practice Address - Phone:617-389-2112
Practice Address - Fax:617-389-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19582261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental