Provider Demographics
NPI:1528575628
Name:MATTAPAN DENTAL, LLC
Entity Type:Organization
Organization Name:MATTAPAN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASHPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-400-5920
Mailing Address - Street 1:220 RESERVOIR ST STE 9
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3133
Mailing Address - Country:US
Mailing Address - Phone:781-400-5920
Mailing Address - Fax:
Practice Address - Street 1:542 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-3014
Practice Address - Country:US
Practice Address - Phone:781-400-5920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental