Provider Demographics
NPI:1629336383
Name:DEDHAM DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DEDHAM DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-329-1234
Mailing Address - Street 1:888 WASHINGTON ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6017
Mailing Address - Country:US
Mailing Address - Phone:781-329-1234
Mailing Address - Fax:
Practice Address - Street 1:888 WASHINGTON ST
Practice Address - Street 2:SUITE 306
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6017
Practice Address - Country:US
Practice Address - Phone:781-329-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA125691223G0001X
MA191321223G0001X
MADN172961223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty