Provider Demographics
NPI:1578909750
Name:TRUSTEES OF BOSTON UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF BOSTON UNIVERSITY
Other - Org Name:BU ORAL SURGERY GROUP PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-638-4780
Mailing Address - Street 1:100 E NEWTON ST
Mailing Address - Street 2:SUITE G407
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-638-4350
Mailing Address - Fax:617-638-4365
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-4350
Practice Address - Fax:617-638-4365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF BOSTON UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110009488CMedicaid
MAX10125Medicare PIN