Provider Demographics
NPI:1437316825
Name:PERIODONTICS DENTAL IMPLANTS OF GREATER BOSTON
Entity type:Organization
Organization Name:PERIODONTICS DENTAL IMPLANTS OF GREATER BOSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTRER-POTAPOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-776-7676
Mailing Address - Street 1:30 COLLEGE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1914
Mailing Address - Country:US
Mailing Address - Phone:617-776-7676
Mailing Address - Fax:617-776-7677
Practice Address - Street 1:30 COLLEGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1914
Practice Address - Country:US
Practice Address - Phone:617-776-7676
Practice Address - Fax:617-776-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty