Provider Demographics
NPI:1336394006
Name:MASSACHUSETTS DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:MASSACHUSETTS DENTAL PROFESSIONALS, P.C.
Other - Org Name:EAST BREWSTER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8434
Mailing Address - Street 1:11 BAY STATE CT
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-2120
Mailing Address - Country:US
Mailing Address - Phone:508-255-0111
Mailing Address - Fax:508-255-1160
Practice Address - Street 1:11 BAY STATE CT
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2120
Practice Address - Country:US
Practice Address - Phone:508-255-0111
Practice Address - Fax:508-255-1160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASSACHUSETTS DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-23
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22060122300000X
MA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty