Provider Demographics
NPI:1295907467
Name:MATTAPAN SQUARE FAMILY DENTAL PC
Entity type:Organization
Organization Name:MATTAPAN SQUARE FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-823-2111
Mailing Address - Street 1:1634 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2121
Mailing Address - Country:US
Mailing Address - Phone:617-298-2000
Mailing Address - Fax:617-298-2002
Practice Address - Street 1:1634 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2121
Practice Address - Country:US
Practice Address - Phone:617-298-2000
Practice Address - Fax:617-298-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203980Medicaid