Provider Demographics
NPI:1417182437
Name:PORTER SQUARE FAMILY DENTAL
Entity Type:Organization
Organization Name:PORTER SQUARE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-547-3934
Mailing Address - Street 1:14 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2712
Mailing Address - Country:US
Mailing Address - Phone:617-547-3934
Mailing Address - Fax:
Practice Address - Street 1:14 UPLAND RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2712
Practice Address - Country:US
Practice Address - Phone:617-547-3934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216411223G0001X
MA222661223G0001X
MA202921223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty