Provider Demographics
NPI:1497977177
Name:FORSYTH DENTAL INFIRMARY FOR CHILDREN
Entity Type:Organization
Organization Name:FORSYTH DENTAL INFIRMARY FOR CHILDREN
Other - Org Name:FORSYTH DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR CENTER FOR EVIDENCE BASED
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-262-5200
Mailing Address - Street 1:140 FENWAY
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-262-5200
Mailing Address - Fax:617-262-4021
Practice Address - Street 1:140 FENWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-262-5200
Practice Address - Fax:617-262-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
MA13692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty