Provider Demographics
NPI:1447382817
Name:COMMONWEALTH OF MASSACHUSETTS-DDS
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS-DDS
Other - Org Name:PLYMOUTH AREA OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-624-7577
Mailing Address - Street 1:500 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2439
Mailing Address - Country:US
Mailing Address - Phone:617-727-5608
Mailing Address - Fax:617-624-7577
Practice Address - Street 1:61 INDUSTRIAL PARK RD
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4868
Practice Address - Country:US
Practice Address - Phone:508-732-3100
Practice Address - Fax:508-747-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
EXEMPT251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1813072Medicaid