Provider Demographics
NPI:1447421094
Name:IDENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:IDENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:XIAO
Authorized Official - Middle Name:
Authorized Official - Last Name:HAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-285-4440
Mailing Address - Street 1:175 MANSFIELD AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:NORTON
Mailing Address - State:MA
Mailing Address - Zip Code:02766-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 MANSFIELD AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-1333
Practice Address - Country:US
Practice Address - Phone:508-285-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0218774Medicaid