Provider Demographics
NPI:1629055793
Name:PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NEALE
Authorized Official - Middle Name:I
Authorized Official - Last Name:ECKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-369-7771
Mailing Address - Street 1:290 BAKER AVE
Mailing Address - Street 2:STE. 228NORTH
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2189
Mailing Address - Country:US
Mailing Address - Phone:978-369-7771
Mailing Address - Fax:978-371-2031
Practice Address - Street 1:290 BAKER AVE
Practice Address - Street 2:STE. 228NORTH
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2189
Practice Address - Country:US
Practice Address - Phone:978-369-7771
Practice Address - Fax:978-371-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA134691223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0296287Medicaid