Provider Demographics
NPI:1922270198
Name:WATER STREET FAMILY DENTAL PC
Entity Type:Organization
Organization Name:WATER STREET FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-823-2111
Mailing Address - Street 1:2 WATER ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6229
Mailing Address - Country:US
Mailing Address - Phone:978-372-1999
Mailing Address - Fax:978-372-1988
Practice Address - Street 1:2 WATER ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6229
Practice Address - Country:US
Practice Address - Phone:978-372-1999
Practice Address - Fax:978-372-1988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203980Medicaid