Provider Demographics
NPI:1598818122
Name:TRUSTEES OF BOSTON UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF BOSTON UNIVERSITY
Other - Org Name:BOSTON UNIVERSITY DENTAL HEALTH CENTER - 930 COMMONWEALTH AVE.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSOR AND DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MED
Authorized Official - Phone:617-638-4780
Mailing Address - Street 1:930 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1274
Mailing Address - Country:US
Mailing Address - Phone:617-358-1000
Mailing Address - Fax:617-358-1010
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1274
Practice Address - Country:US
Practice Address - Phone:617-358-1000
Practice Address - Fax:617-358-1010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF BOSTON UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49541223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0400X, 124Q00000X, 126800000X, 126900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty
No126900000XDental ProvidersDental Laboratory TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========NOtherBLUE CROSS BLUE SHIELD
MA=========NOtherAMERITAS
MA=========NOtherMETLIFE
MA=========NOtherDELTA PREMIER
MA=========NOtherDELTA DENTAL