Provider Demographics
NPI:1881852713
Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Entity Type:Organization
Organization Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Other - Org Name:HARVARD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:617-432-1401
Mailing Address - Street 1:188 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5819
Mailing Address - Country:US
Mailing Address - Phone:617-432-1401
Mailing Address - Fax:617-432-4258
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1401
Practice Address - Fax:617-432-4258
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA372301223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0200140Medicaid