Provider Demographics
NPI:1881024545
Name:CROWNING MOMENT LLC
Entity Type:Organization
Organization Name:CROWNING MOMENT LLC
Other - Org Name:BLUE HILLS DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK SSU-CHIEH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-953-1824
Mailing Address - Street 1:340 WOOD RD
Mailing Address - Street 2:SUITE 288
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-2401
Mailing Address - Country:US
Mailing Address - Phone:617-953-1824
Mailing Address - Fax:
Practice Address - Street 1:340 WOOD RD
Practice Address - Street 2:SUITE 288
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2401
Practice Address - Country:US
Practice Address - Phone:617-953-1824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-16
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855439305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization