Provider Demographics
NPI:1205061207
Name:COMMUNITY FAMILY DENTAL
Entity type:Organization
Organization Name:COMMUNITY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-285-6414
Mailing Address - Street 1:648 AMERICAN LEGION HWY
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3901
Mailing Address - Country:US
Mailing Address - Phone:617-699-9894
Mailing Address - Fax:
Practice Address - Street 1:648 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3901
Practice Address - Country:US
Practice Address - Phone:617-699-9894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA186431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0277975Medicaid