Provider Demographics
NPI:1689003063
Name:VAST DENTAL LLC
Entity Type:Organization
Organization Name:VAST DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOANG
Authorized Official - Middle Name:ANH
Authorized Official - Last Name:THU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-996-5322
Mailing Address - Street 1:433 WATERTOWN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1113
Mailing Address - Country:US
Mailing Address - Phone:978-996-5322
Mailing Address - Fax:
Practice Address - Street 1:433 WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1113
Practice Address - Country:US
Practice Address - Phone:978-996-5322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN 18551181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty