Provider Demographics
NPI:1952052235
Name:WESTERN MASS PERIODONTICS PC
Entity Type:Organization
Organization Name:WESTERN MASS PERIODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MAYLOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-874-8198
Mailing Address - Street 1:65 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2547
Mailing Address - Country:US
Mailing Address - Phone:860-874-8198
Mailing Address - Fax:
Practice Address - Street 1:75 BERLIN RD STE 108
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2633
Practice Address - Country:US
Practice Address - Phone:860-635-1515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MASS PERIODONTICS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty