Provider Demographics
NPI:1629116355
Name:WEBSTER SQUARE DENTAL
Entity Type:Organization
Organization Name:WEBSTER SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-753-6777
Mailing Address - Street 1:17 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-1420
Mailing Address - Country:US
Mailing Address - Phone:508-753-6777
Mailing Address - Fax:508-753-0206
Practice Address - Street 1:17 YOUNG ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1420
Practice Address - Country:US
Practice Address - Phone:508-753-6777
Practice Address - Fax:508-753-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA198101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9712470Medicaid
MA0202991Medicaid
MA0208281Medicaid
MA0282073Medicaid