Provider Demographics
NPI:1710043385
Name:CHANDLER DENTAL PC
Entity Type:Organization
Organization Name:CHANDLER DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER & SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:SIR
Authorized Official - Middle Name:HAO
Authorized Official - Last Name:FOO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:508-754-5226
Mailing Address - Street 1:372 CHANDLER ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-3300
Mailing Address - Country:US
Mailing Address - Phone:508-754-5226
Mailing Address - Fax:508-754-5228
Practice Address - Street 1:372 CHANDLER ST
Practice Address - Street 2:SUITE 10
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-3300
Practice Address - Country:US
Practice Address - Phone:508-754-5226
Practice Address - Fax:508-754-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9754610Medicaid