Provider Demographics
NPI:1629231709
Name:GROTON DENTAL WELLNESS CENTER
Entity Type:Organization
Organization Name:GROTON DENTAL WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NORDIN-EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-449-9919
Mailing Address - Street 1:495 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450
Mailing Address - Country:US
Mailing Address - Phone:978-449-9919
Mailing Address - Fax:978-449-9929
Practice Address - Street 1:495 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450
Practice Address - Country:US
Practice Address - Phone:978-449-9919
Practice Address - Fax:978-449-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty