Provider Demographics
NPI:1417144965
Name:ELITE DENTAL, INC.
Entity Type:Organization
Organization Name:ELITE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-281-2978
Mailing Address - Street 1:4 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2578
Mailing Address - Country:US
Mailing Address - Phone:617-281-2978
Mailing Address - Fax:978-658-2579
Practice Address - Street 1:1540 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2215
Practice Address - Country:US
Practice Address - Phone:617-738-1950
Practice Address - Fax:978-658-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty