Provider Demographics
NPI:1710030986
Name:CAMBRIDGE PEDIATRIC DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:CAMBRIDGE PEDIATRIC DENTAL ASSOCIATES, P.C.
Other - Org Name:GEORGE W. MCEACHERN III, DMD, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WELLINGTON
Authorized Official - Last Name:MCEACHERN
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-491-1161
Mailing Address - Street 1:1749 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2217
Mailing Address - Country:US
Mailing Address - Phone:617-491-1161
Mailing Address - Fax:
Practice Address - Street 1:1749 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2217
Practice Address - Country:US
Practice Address - Phone:617-491-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9732985Medicaid