Provider Demographics
NPI:1710156930
Name:LAKEVILLE DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:LAKEVILLE DENTAL ASSOCIATES, P.C.
Other - Org Name:LAKEVILLE DENTAL ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-923-6900
Mailing Address - Street 1:54 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-3621
Mailing Address - Country:US
Mailing Address - Phone:508-923-6900
Mailing Address - Fax:508-946-0306
Practice Address - Street 1:54 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-3621
Practice Address - Country:US
Practice Address - Phone:508-923-6900
Practice Address - Fax:508-946-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20826261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12180OtherBCBS OF MA
MA1811540OtherUNITED CONCORDIA