Provider Demographics
NPI:1689007908
Name:CONVIVIAL DENTAL PC
Entity Type:Organization
Organization Name:CONVIVIAL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVRAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, DMSC
Authorized Official - Phone:617-818-0573
Mailing Address - Street 1:64 PINE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-2426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 BOYLSTON ST STE 205
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2115
Practice Address - Country:US
Practice Address - Phone:617-818-0573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855922261QD0000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty