Provider Demographics
NPI:1134496904
Name:FRESH POND DENTAL LLC
Entity type:Organization
Organization Name:FRESH POND DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-285-6414
Mailing Address - Street 1:180 ALEWIFE BROOK PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1102
Mailing Address - Country:US
Mailing Address - Phone:617-547-0700
Mailing Address - Fax:
Practice Address - Street 1:180 ALEWIFE BROOK PKWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1102
Practice Address - Country:US
Practice Address - Phone:617-547-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18643261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental