Provider Demographics
NPI:1629527601
Name:BEACON DENTAL HEALTH
Entity Type:Organization
Organization Name:BEACON DENTAL HEALTH
Other - Org Name:CHESTNUT HILL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RISHI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-418-6940
Mailing Address - Street 1:198 TREMONT ST
Mailing Address - Street 2:SUITE 436
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-4705
Mailing Address - Country:US
Mailing Address - Phone:617-418-6940
Mailing Address - Fax:
Practice Address - Street 1:631 VFW PKWY
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3656
Practice Address - Country:US
Practice Address - Phone:617-418-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON DENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN21699261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental