Provider Demographics
NPI:1134367584
Name:DYNAMIC DENTAL P.C.
Entity type:Organization
Organization Name:DYNAMIC DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDITA
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTERICKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-261-9261
Mailing Address - Street 1:200 CHAUNCY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1200
Mailing Address - Country:US
Mailing Address - Phone:508-261-9261
Mailing Address - Fax:508-261-9261
Practice Address - Street 1:200 CHAUNCY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1200
Practice Address - Country:US
Practice Address - Phone:508-261-9261
Practice Address - Fax:508-261-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty