Provider Demographics
NPI:1265164081
Name:NEDG - BACK BAY PLLC
Entity type:Organization
Organization Name:NEDG - BACK BAY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SYSTEMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-281-6464
Mailing Address - Street 1:257 TURNPIKE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1791
Mailing Address - Country:US
Mailing Address - Phone:508-281-6464
Mailing Address - Fax:
Practice Address - Street 1:811 BOYLSTON ST STE 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2679
Practice Address - Country:US
Practice Address - Phone:617-267-3993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty