Provider Demographics
NPI:1457636029
Name:TUFTS ORAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:TUFTS ORAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-636-3932
Mailing Address - Street 1:1 KNEELAND ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-3932
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST FL 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-3932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF TUFTS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12641261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental