Provider Demographics
NPI:1710013172
Name:BOSTON DENTAL
Entity Type:Organization
Organization Name:BOSTON DENTAL
Other - Org Name:FRED G. BOUSTANY D.M.D.,PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOUSTANY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-338-5000
Mailing Address - Street 1:36 CHAUNCY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-2209
Mailing Address - Country:US
Mailing Address - Phone:617-338-5000
Mailing Address - Fax:617-338-1039
Practice Address - Street 1:36 CHAUNCY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-2209
Practice Address - Country:US
Practice Address - Phone:617-338-5000
Practice Address - Fax:617-338-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty