Provider Demographics
NPI:1558023077
Name:IDG SCITUATE DENTAL PC
Entity Type:Organization
Organization Name:IDG SCITUATE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEEJU
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-262-5308
Mailing Address - Street 1:754 COUNTRY WAY
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1825
Mailing Address - Country:US
Mailing Address - Phone:781-545-4181
Mailing Address - Fax:781-545-3928
Practice Address - Street 1:754 COUNTRY WAY
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-1825
Practice Address - Country:US
Practice Address - Phone:781-545-4181
Practice Address - Fax:781-545-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental