Provider Demographics
NPI:1548596398
Name:WESTERN MASS PERIODONTICS, LLC
Entity Type:Organization
Organization Name:WESTERN MASS PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-596-0009
Mailing Address - Street 1:85 POST OFFICE PARK
Mailing Address - Street 2:SUITE 8503
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1247
Mailing Address - Country:US
Mailing Address - Phone:413-596-0009
Mailing Address - Fax:
Practice Address - Street 1:85 POST OFFICE PARK
Practice Address - Street 2:SUITE 8503
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1247
Practice Address - Country:US
Practice Address - Phone:413-596-0009
Practice Address - Fax:413-596-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty