Provider Demographics
NPI:1558782409
Name:COPPE PEDIATRIC DENTAL LLC
Entity Type:Organization
Organization Name:COPPE PEDIATRIC DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-861-6120
Mailing Address - Street 1:19 MUZZEY ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 MUZZEY ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5256
Practice Address - Country:US
Practice Address - Phone:781-861-6120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty