Provider Demographics
NPI:1295173334
Name:DAVIS SQUARE DENTAL SPECIALISTS LLC
Entity type:Organization
Organization Name:DAVIS SQUARE DENTAL SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KITIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-975-1000
Mailing Address - Street 1:335 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1262
Mailing Address - Country:US
Mailing Address - Phone:978-975-1000
Mailing Address - Fax:978-975-1004
Practice Address - Street 1:335 COMMON ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1262
Practice Address - Country:US
Practice Address - Phone:978-975-1000
Practice Address - Fax:978-975-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty