Provider Demographics
NPI:1750328670
Name:BELMONT PERIODONTICS, P.C.
Entity Type:Organization
Organization Name:BELMONT PERIODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-484-0475
Mailing Address - Street 1:18 MOORE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-2525
Mailing Address - Country:US
Mailing Address - Phone:617-484-0475
Mailing Address - Fax:
Practice Address - Street 1:18 MOORE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-2525
Practice Address - Country:US
Practice Address - Phone:617-484-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15531OtherDENTAL LICENSE