Provider Demographics
NPI:1508088857
Name:ANTHONY C BROCCOLI JR DMD INC
Entity Type:Organization
Organization Name:ANTHONY C BROCCOLI JR DMD INC
Other - Org Name:ANDOVER ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROCCOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-475-0450
Mailing Address - Street 1:15 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810
Mailing Address - Country:US
Mailing Address - Phone:978-475-0450
Mailing Address - Fax:
Practice Address - Street 1:15 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-0450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty