Provider Demographics
NPI:1760870497
Name:NORTHBOROUGH FAMILY DENTAL, PC
Entity Type:Organization
Organization Name:NORTHBOROUGH FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOHEBAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-393-2522
Mailing Address - Street 1:154 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1930
Mailing Address - Country:US
Mailing Address - Phone:508-393-2522
Mailing Address - Fax:508-393-9782
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1930
Practice Address - Country:US
Practice Address - Phone:508-393-2522
Practice Address - Fax:508-393-9782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1855167261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental