Provider Demographics
NPI:1821479445
Name:SOUTH STREET DENTAL LLC
Entity Type:Organization
Organization Name:SOUTH STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIMBLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-934-5227
Mailing Address - Street 1:276 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7044
Mailing Address - Country:US
Mailing Address - Phone:617-934-5227
Mailing Address - Fax:
Practice Address - Street 1:276 SOUTH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7044
Practice Address - Country:US
Practice Address - Phone:617-934-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty