Provider Demographics
NPI:1407907249
Name:CENTRAL SQUARE FAMILY DENTAL PC
Entity Type:Organization
Organization Name:CENTRAL SQUARE FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-868-9400
Mailing Address - Street 1:714 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3308
Mailing Address - Country:US
Mailing Address - Phone:617-868-9400
Mailing Address - Fax:
Practice Address - Street 1:714 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3308
Practice Address - Country:US
Practice Address - Phone:617-868-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203980Medicaid