Provider Demographics
NPI:1841766433
Name:MARLBOROUGH DENTAL SPECIALTIES, PC
Entity Type:Organization
Organization Name:MARLBOROUGH DENTAL SPECIALTIES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:5 MOUNT ROYAL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1900
Mailing Address - Country:US
Mailing Address - Phone:508-872-3072
Mailing Address - Fax:
Practice Address - Street 1:116 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3811
Practice Address - Country:US
Practice Address - Phone:774-374-2327
Practice Address - Fax:774-374-2328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty