Provider Demographics
NPI:1013153048
Name:BRIGHTON DENTAL GROUP LLC
Entity Type:Organization
Organization Name:BRIGHTON DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NOPSARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAIMATTAYOMPOL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-782-5455
Mailing Address - Street 1:1607 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4214
Mailing Address - Country:US
Mailing Address - Phone:617-782-5455
Mailing Address - Fax:617-782-5452
Practice Address - Street 1:1607 COMMONWEALTH AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-4214
Practice Address - Country:US
Practice Address - Phone:617-782-5455
Practice Address - Fax:617-782-5452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207891223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty