Provider Demographics
NPI:1710109541
Name:SEAPORT DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:SEAPORT DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:917-608-8055
Mailing Address - Street 1:799 E BROADWAY
Mailing Address - Street 2:APT #3
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2346
Mailing Address - Country:US
Mailing Address - Phone:917-608-8055
Mailing Address - Fax:
Practice Address - Street 1:451 D ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-1950
Practice Address - Country:US
Practice Address - Phone:917-608-8055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty