Provider Demographics
NPI:1467676379
Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF THE NORTH SHORE L.L.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY AND ORTHODONTICS OF THE NORTH SHORE L.L.C.
Other - Org Name:DR. DONALD NELSON, D.M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-774-1822
Mailing Address - Street 1:6 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2567
Mailing Address - Country:US
Mailing Address - Phone:978-774-1822
Mailing Address - Fax:978-774-1734
Practice Address - Street 1:6 STATE RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2567
Practice Address - Country:US
Practice Address - Phone:978-774-1822
Practice Address - Fax:978-774-1734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX10612OtherBLUE CROSS BLUE SHIELD #
MA=========OtherTAX ID #