Provider Demographics
NPI:1750828752
Name:COREDENTAL, LLC
Entity Type:Organization
Organization Name:COREDENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NAFASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-634-9393
Mailing Address - Street 1:611 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1319
Mailing Address - Country:US
Mailing Address - Phone:617-651-5255
Mailing Address - Fax:617-481-6635
Practice Address - Street 1:611 ADAMS ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1319
Practice Address - Country:US
Practice Address - Phone:617-479-9191
Practice Address - Fax:617-481-6635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18563761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty