Provider Demographics
NPI:1336171115
Name:LEICESTER DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LEICESTER DENTAL ASSOCIATES
Other - Org Name:JOHN J MILLETTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-892-4882
Mailing Address - Street 1:119 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01524-1403
Mailing Address - Country:US
Mailing Address - Phone:508-892-4882
Mailing Address - Fax:508-892-4279
Practice Address - Street 1:119 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:MA
Practice Address - Zip Code:01524-1403
Practice Address - Country:US
Practice Address - Phone:508-892-4882
Practice Address - Fax:508-892-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179841223G0001X
MA967101223G0001X
MA206021223P0300X
MA193881223S0112X
MA179651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11875OtherBCBS