Provider Demographics
NPI:1003579277
Name:CEDAR BROOK PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:CEDAR BROOK PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:LA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-817-6346
Mailing Address - Street 1:302 BAY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 CORDAVILLE RD STE 175
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1838
Practice Address - Country:US
Practice Address - Phone:617-817-6346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty