Provider Demographics
NPI:1710382676
Name:CONANT STREET DENTAL LLC
Entity Type:Organization
Organization Name:CONANT STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEUNGHEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-774-3331
Mailing Address - Street 1:36 CONANT ST STE 4
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2954
Mailing Address - Country:US
Mailing Address - Phone:978-774-3331
Mailing Address - Fax:978-774-3331
Practice Address - Street 1:36 CONANT ST STE 4
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2954
Practice Address - Country:US
Practice Address - Phone:978-774-3331
Practice Address - Fax:978-774-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN222721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1871741983OtherNPI