Provider Demographics
NPI:1750689576
Name:THE LOOSE TOOTH
Entity Type:Organization
Organization Name:THE LOOSE TOOTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OPPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, PHDH
Authorized Official - Phone:1413-888-6767
Mailing Address - Street 1:874 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-3107
Mailing Address - Country:US
Mailing Address - Phone:413-888-6767
Mailing Address - Fax:413-888-6766
Practice Address - Street 1:874 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-3107
Practice Address - Country:US
Practice Address - Phone:413-888-6767
Practice Address - Fax:413-888-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH11413302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization