Provider Demographics
NPI:1295400588
Name:MEDFORD SQUARE DENTISTRY AND IMPLANTS LLC
Entity type:Organization
Organization Name:MEDFORD SQUARE DENTISTRY AND IMPLANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:YADAV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:573-639-0497
Mailing Address - Street 1:20 SUMMER ST APT 903
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3914
Mailing Address - Country:US
Mailing Address - Phone:573-639-0497
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-7102
Practice Address - Country:US
Practice Address - Phone:781-391-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental