Provider Demographics
NPI:1821153586
Name:BAY STATE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:BAY STATE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Other - Org Name:JOHN M RISTUCCIA, DDS AND ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RISTUCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-686-4187
Mailing Address - Street 1:100 AMESBURY ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1321
Mailing Address - Country:US
Mailing Address - Phone:978-686-4187
Mailing Address - Fax:978-686-0941
Practice Address - Street 1:100 AMESBURY ST
Practice Address - Street 2:SUITE 112
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1321
Practice Address - Country:US
Practice Address - Phone:978-686-4187
Practice Address - Fax:978-686-0941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0024745OtherCIGNA HEALTHCARE
MA585304OtherUNITED CONCORDIA
MAM11729OtherBLUE CROSS BLUE SHIELD
MA600593OtherTUFTS HEALTH PLAN
MA689643OtherTUFTS HEALTH PLAN
MAX10821OtherBLUE CROSS BLUE SHIELD
MA0024745OtherCIGNA HEALTHCARE
MA600593OtherTUFTS HEALTH PLAN
MA=========OtherHEALTH CARE VALUE MANAGEM
MAM11729Medicare ID - Type UnspecifiedMEDICARE