Provider Demographics
NPI:1184323248
Name:EZ DENTAL GROUP LLC
Entity type:Organization
Organization Name:EZ DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOU-EZZI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-801-4903
Mailing Address - Street 1:555 TURNPIKE ST STE 55
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5935
Mailing Address - Country:US
Mailing Address - Phone:508-801-4903
Mailing Address - Fax:
Practice Address - Street 1:156 MAIN ST UNIT 1
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:MA
Practice Address - Zip Code:01834-1311
Practice Address - Country:US
Practice Address - Phone:978-521-2922
Practice Address - Fax:978-521-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1164579389Medicaid