Provider Demographics
NPI:1619066917
Name:BROCKTON NEIGHBORHOOD H. C.
Entity Type:Organization
Organization Name:BROCKTON NEIGHBORHOOD H. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISRY
Authorized Official - Prefix:
Authorized Official - First Name:JULIUS
Authorized Official - Middle Name:N
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:MDS
Authorized Official - Phone:508-584-2708
Mailing Address - Street 1:231 MAIN ST
Mailing Address - Street 2:200
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4342
Mailing Address - Country:US
Mailing Address - Phone:508-584-2708
Mailing Address - Fax:508-559-1158
Practice Address - Street 1:231 MAIN ST
Practice Address - Street 2:302
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4342
Practice Address - Country:US
Practice Address - Phone:508-559-1567
Practice Address - Fax:508-559-5073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1210420305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization