Provider Demographics
NPI:1619003548
Name:THERESE H VENEDIKIAN DMD PC
Entity Type:Organization
Organization Name:THERESE H VENEDIKIAN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:H
Authorized Official - Last Name:VENEDIKIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-393-8877
Mailing Address - Street 1:84 HIGH ST
Mailing Address - Street 2:STE 7
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3844
Mailing Address - Country:US
Mailing Address - Phone:781-393-8877
Mailing Address - Fax:781-393-0040
Practice Address - Street 1:84 HIGH ST
Practice Address - Street 2:STE 7
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3844
Practice Address - Country:US
Practice Address - Phone:781-393-8877
Practice Address - Fax:781-393-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA182381223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX07111OtherBCBS