Provider Demographics
NPI:1801208715
Name:ARCH ST DENTAL CORP
Entity Type:Organization
Organization Name:ARCH ST DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EKATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMULASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-338-7778
Mailing Address - Street 1:103 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1102
Mailing Address - Country:US
Mailing Address - Phone:617-338-7778
Mailing Address - Fax:617-338-7779
Practice Address - Street 1:103 ARCH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1102
Practice Address - Country:US
Practice Address - Phone:617-338-7778
Practice Address - Fax:617-338-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty