Provider Demographics
NPI:1578882635
Name:SVEN SUPPLIES DMD, PC
Entity Type:Organization
Organization Name:SVEN SUPPLIES DMD, PC
Other - Org Name:GREAT ROAD ORTHODONTICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPPLIES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-263-8358
Mailing Address - Street 1:179 GREAT RD
Mailing Address - Street 2:SUIUTE 206
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-5777
Mailing Address - Country:US
Mailing Address - Phone:978-263-8358
Mailing Address - Fax:978-263-9260
Practice Address - Street 1:179 GREAT RD
Practice Address - Street 2:SUIUTE 206
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5777
Practice Address - Country:US
Practice Address - Phone:978-263-8358
Practice Address - Fax:978-263-9260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18956261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental