Provider Demographics
NPI:1407908213
Name:CLASS ONE ORTHODONTIC ASSO LLC
Entity Type:Organization
Organization Name:CLASS ONE ORTHODONTIC ASSO LLC
Other - Org Name:FAEZE FADIANI DMD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAEZE
Authorized Official - Middle Name:
Authorized Official - Last Name:FADIANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:508-853-4003
Mailing Address - Street 1:365 BURNCOAT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606
Mailing Address - Country:US
Mailing Address - Phone:508-853-4003
Mailing Address - Fax:508-854-8305
Practice Address - Street 1:365 BURNCOAT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-4003
Practice Address - Fax:508-854-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147741223X0400X
MA207171223X0400X
1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0260398Medicaid