Provider Demographics
NPI:1972761807
Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Entity Type:Organization
Organization Name:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Other - Org Name:HARVARD DENTAL CENTER TP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DA SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-432-1440
Mailing Address - Street 1:188 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5819
Mailing Address - Country:US
Mailing Address - Phone:617-432-1440
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0200140Medicaid