Provider Demographics
NPI:1790330298
Name:CAMBRIDGE PERIODONTICS LLC
Entity Type:Organization
Organization Name:CAMBRIDGE PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DERKAZARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-864-5444
Mailing Address - Street 1:1692 MASSACHUSETTS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-864-5444
Mailing Address - Fax:
Practice Address - Street 1:1692 MASSACHUSETTS AVE STE 3
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-864-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty