Provider Demographics
NPI:1992203111
Name:SPROUT KIDS DENTISTRY OF QUINCY, LLC
Entity Type:Organization
Organization Name:SPROUT KIDS DENTISTRY OF QUINCY, LLC
Other - Org Name:SPROUT KIDS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-947-6557
Mailing Address - Street 1:1250 HANCOCK ST STE 110N-B
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4339
Mailing Address - Country:US
Mailing Address - Phone:617-947-6557
Mailing Address - Fax:
Practice Address - Street 1:1250 HANCOCK ST STE 110N-B
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4339
Practice Address - Country:US
Practice Address - Phone:617-947-6557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty