Provider Demographics
NPI:1598485484
Name:BRAIN DENTAL PLLC
Entity Type:Organization
Organization Name:BRAIN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LIGHTFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-780-0565
Mailing Address - Street 1:10 SHIPYARD DR APT 206
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1680
Mailing Address - Country:US
Mailing Address - Phone:617-780-0565
Mailing Address - Fax:
Practice Address - Street 1:400 WASHINGTON ST STE 304
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4768
Practice Address - Country:US
Practice Address - Phone:781-848-2775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty