Provider Demographics
NPI:1245499904
Name:37 MAIN STREET
Entity type:Organization
Organization Name:37 MAIN STREET
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLEHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-881-7700
Mailing Address - Street 1:37 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-1104
Mailing Address - Country:US
Mailing Address - Phone:508-881-7700
Mailing Address - Fax:508-881-7049
Practice Address - Street 1:37 MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-1104
Practice Address - Country:US
Practice Address - Phone:508-881-7700
Practice Address - Fax:508-881-7049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18556122300000X
MA21446122300000X
MA18296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty