Provider Demographics
NPI:1922513597
Name:BOYLSTON STREET DENTAL, LLC
Entity Type:Organization
Organization Name:BOYLSTON STREET DENTAL, LLC
Other - Org Name:BOYLSTON STREET DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:POLIVY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-566-6900
Mailing Address - Street 1:300 BOYLSTON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1959
Mailing Address - Country:US
Mailing Address - Phone:617-566-6900
Mailing Address - Fax:
Practice Address - Street 1:300 BOYLSTON ST STE 202
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1959
Practice Address - Country:US
Practice Address - Phone:617-566-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty