Provider Demographics
NPI:1134456346
Name:BROOKLINE DENTURE CENTER, LLC
Entity type:Organization
Organization Name:BROOKLINE DENTURE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERDJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KILADJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-738-1232
Mailing Address - Street 1:1842 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-1930
Mailing Address - Country:US
Mailing Address - Phone:617-738-1232
Mailing Address - Fax:617-730-8482
Practice Address - Street 1:1842 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-1930
Practice Address - Country:US
Practice Address - Phone:617-738-1232
Practice Address - Fax:617-730-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA189641223G0001X
MA104261223S0112X
MA17049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty