Provider Demographics
NPI:1518235365
Name:DR.DENTAL OF REVERE, P.C.
Entity Type:Organization
Organization Name:DR.DENTAL OF REVERE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCKAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-420-9920
Mailing Address - Street 1:339 SQUIRE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4309
Mailing Address - Country:US
Mailing Address - Phone:781-286-7510
Mailing Address - Fax:781-286-7513
Practice Address - Street 1:339 SQUIRE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4309
Practice Address - Country:US
Practice Address - Phone:781-286-7510
Practice Address - Fax:781-286-7513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN20485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty