Provider Demographics
NPI:1891182242
Name:DENTISTRY ON PARK, LLC
Entity Type:Organization
Organization Name:DENTISTRY ON PARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DOURAGHY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-341-8966
Mailing Address - Street 1:19 PARK ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-2913
Mailing Address - Country:US
Mailing Address - Phone:781-341-8966
Mailing Address - Fax:
Practice Address - Street 1:19 PARK ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-2913
Practice Address - Country:US
Practice Address - Phone:781-341-8966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty