Provider Demographics
NPI:1871249771
Name:WORCESTER COSMETIC AND RESTORATIVE DENTISTRY GROUP PC
Entity Type:Organization
Organization Name:WORCESTER COSMETIC AND RESTORATIVE DENTISTRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-533-8501
Mailing Address - Street 1:301 LAKE SHORE DR APT 608
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-3501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 W BOYLSTON ST STE 203
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1274
Practice Address - Country:US
Practice Address - Phone:603-533-8501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty