Provider Demographics
NPI:1245665892
Name:WELLESLEY FAMILY DENTAL
Entity type:Organization
Organization Name:WELLESLEY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSKOWITZ-PORATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-308-8323
Mailing Address - Street 1:20 COTTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-2620
Mailing Address - Country:US
Mailing Address - Phone:617-308-8323
Mailing Address - Fax:
Practice Address - Street 1:310 WASHINGTON ST STE 208
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-4949
Practice Address - Country:US
Practice Address - Phone:617-398-8323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN19097261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental