Provider Demographics
NPI:1457863953
Name:MEDFORD TLC DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:MEDFORD TLC DENTAL GROUP, LLC
Other - Org Name:TLC DENTAL OF MEDFORD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANOPOLSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-393-0008
Mailing Address - Street 1:84 HIGH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3844
Mailing Address - Country:US
Mailing Address - Phone:781-393-0008
Mailing Address - Fax:
Practice Address - Street 1:84 HIGH ST STE 5
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3844
Practice Address - Country:US
Practice Address - Phone:781-393-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN196181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty