Provider Demographics
NPI:1417484395
Name:PEDERSEN, JADE (DMD)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 MASSACHUSETTS AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1110
Mailing Address - Country:US
Mailing Address - Phone:617-459-9844
Mailing Address - Fax:
Practice Address - Street 1:368 W BROADWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2272
Practice Address - Country:US
Practice Address - Phone:617-269-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist