Provider Demographics
NPI:1417128042
Name:THE PRACTICE OF ANESTHESIA & GEN. DENTISTRY
Entity Type:Organization
Organization Name:THE PRACTICE OF ANESTHESIA & GEN. DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN. DENTIST & ANESTHESIOLOGIST/OWN
Authorized Official - Prefix:
Authorized Official - First Name:LUE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:800-676-2750
Mailing Address - Street 1:18 CLAREMONT PARK
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3002
Mailing Address - Country:US
Mailing Address - Phone:800-676-2750
Mailing Address - Fax:
Practice Address - Street 1:386 A/B WARREN STREET
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-0000
Practice Address - Country:US
Practice Address - Phone:800-676-2750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUE DEE JACKSON JR. DMD, MD DBA THE PRACTICE OF ANESTH. & GEN. DENT.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15374261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0262331Medicaid