Provider Demographics
NPI:1245882604
Name:42 NORTH DENTAL CARE, LLC
Entity type:Organization
Organization Name:42 NORTH DENTAL CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-290-3010
Mailing Address - Street 1:200 5TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8759
Mailing Address - Country:US
Mailing Address - Phone:781-647-0772
Mailing Address - Fax:781-895-9995
Practice Address - Street 1:188 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464-1596
Practice Address - Country:US
Practice Address - Phone:857-299-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:42 NORTH DENTAL CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-15
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental