Provider Demographics
NPI:1689012361
Name:RIVERSIDE DENTAL LLC
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA MOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANISH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-738-6808
Mailing Address - Street 1:235B MEMORIAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2846
Mailing Address - Country:US
Mailing Address - Phone:603-738-6808
Mailing Address - Fax:413-285-8146
Practice Address - Street 1:235B MEMORIAL AVENUE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01028-2846
Practice Address - Country:US
Practice Address - Phone:603-738-6808
Practice Address - Fax:413-285-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18551341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty