Provider Demographics
NPI:1821601170
Name:CLEAN AND SEAL DENTAL PROGRAM
Entity Type:Organization
Organization Name:CLEAN AND SEAL DENTAL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, BSDH, MED
Authorized Official - Phone:774-321-4720
Mailing Address - Street 1:172 ASHMONT ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3745
Mailing Address - Country:US
Mailing Address - Phone:774-321-4720
Mailing Address - Fax:
Practice Address - Street 1:172 ASHMONT ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3745
Practice Address - Country:US
Practice Address - Phone:774-321-4720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare