Provider Demographics
NPI:1952658056
Name:MASS KIDZ HEALTHY SMILES LLC
Entity Type:Organization
Organization Name:MASS KIDZ HEALTHY SMILES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUISI
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:617-913-3321
Mailing Address - Street 1:126 AUDUBON AVE
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-2352
Mailing Address - Country:US
Mailing Address - Phone:617-913-3321
Mailing Address - Fax:781-817-6135
Practice Address - Street 1:126 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2352
Practice Address - Country:US
Practice Address - Phone:617-913-3321
Practice Address - Fax:781-817-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH11340302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization