Provider Demographics
NPI:1619351269
Name:VENUSDENTALPC
Entity Type:Organization
Organization Name:VENUSDENTALPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISTOWNER
Authorized Official - Prefix:
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-298-5281
Mailing Address - Street 1:63 GREAT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2097
Mailing Address - Country:US
Mailing Address - Phone:978-298-5281
Mailing Address - Fax:
Practice Address - Street 1:63 GREAT RD STE 105
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2097
Practice Address - Country:US
Practice Address - Phone:978-298-5281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856317305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization