Provider Demographics
NPI:1023586062
Name:NEDG WILMINGTON
Entity type:Organization
Organization Name:NEDG WILMINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GOKULAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THIAGARAJAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-962-2332
Mailing Address - Street 1:257 TURNPIKE RD STE 330
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1791
Mailing Address - Country:US
Mailing Address - Phone:508-281-6464
Mailing Address - Fax:
Practice Address - Street 1:206 BALLARDVALE ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-1044
Practice Address - Country:US
Practice Address - Phone:508-962-2332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========OtherTAX ID