Provider Demographics
NPI:1467721969
Name:CITY DENTAL LLC
Entity Type:Organization
Organization Name:CITY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CIELITO
Authorized Official - Middle Name:DE
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-942-5051
Mailing Address - Street 1:439 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3612
Mailing Address - Country:US
Mailing Address - Phone:617-944-9627
Mailing Address - Fax:617-944-9742
Practice Address - Street 1:439 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3612
Practice Address - Country:US
Practice Address - Phone:617-944-9627
Practice Address - Fax:617-944-9742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN8735122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1548321235Medicaid