Provider Demographics
NPI:1629567243
Name:MILLIS DENTAL CARE, PC
Entity Type:Organization
Organization Name:MILLIS DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-241-6254
Mailing Address - Street 1:28 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1534
Mailing Address - Country:US
Mailing Address - Phone:617-999-7686
Mailing Address - Fax:
Practice Address - Street 1:MILLIS DENTAL CARE, PC
Practice Address - Street 2:840 MAIN STREET, SUITE 112
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1542
Practice Address - Country:US
Practice Address - Phone:508-556-0882
Practice Address - Fax:508-376-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18566911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty