Provider Demographics
NPI:1790955318
Name:TRUSTEES OF TUFTS COLLEGE
Entity Type:Organization
Organization Name:TRUSTEES OF TUFTS COLLEGE
Other - Org Name:TUFTS CRANIOFACIAL PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEOPOLDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORREA
Authorized Official - Suffix:
Authorized Official - Credentials:BDS, MS
Authorized Official - Phone:617-636-3421
Mailing Address - Street 1:1 KNEELAND ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-6817
Mailing Address - Fax:617-636-3831
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6817
Practice Address - Fax:617-636-3831
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF TUFTS COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-11
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223X2210X
MA4105261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty