Provider Demographics
NPI:1922272921
Name:TRUSTEES OF BOSTON UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF BOSTON UNIVERSITY
Other - Org Name:BOSTON UNIVERSITY GOLDMAN SCHOOL OF DENTAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN AD INTERIM
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MED
Authorized Official - Phone:617-638-4780
Mailing Address - Street 1:100 E NEWTON ST
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-638-4705
Mailing Address - Fax:617-638-4713
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:RM G-401
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4705
Practice Address - Fax:617-638-4713
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTEES OF BOSTON UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49541223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0400X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty