Provider Demographics
NPI:1598043630
Name:BLACKSTONE VALLEY FAMILY DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:BLACKSTONE VALLEY FAMILY DENTAL ASSOCIATES
Other - Org Name:RI DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-450-2177
Mailing Address - Street 1:465 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:401-270-3997
Practice Address - Street 1:465 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-1728
Practice Address - Country:US
Practice Address - Phone:401-450-2177
Practice Address - Fax:401-450-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN03141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty