Provider Demographics
NPI:1679225965
Name:42 NORTH DENTAL CARE OF INDIANA, LLC
Entity Type:Organization
Organization Name:42 NORTH DENTAL CARE OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:SCIALABBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-512-2709
Mailing Address - Street 1:200 5TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 5TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-8759
Practice Address - Country:US
Practice Address - Phone:781-647-0772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:42 NORTH DENTAL CARE OF INDIANA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental