Provider Demographics
NPI:1396939583
Name:CHILDREN'S DENTISTRY OF NORTHBOROUGH
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF NORTHBOROUGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOLANTA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-393-9394
Mailing Address - Street 1:38 SW CUTOFF
Mailing Address - Street 2:SUITE D
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2159
Mailing Address - Country:US
Mailing Address - Phone:508-393-9394
Mailing Address - Fax:508-393-9364
Practice Address - Street 1:38 SW CUTOFF
Practice Address - Street 2:SUITE D
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-2159
Practice Address - Country:US
Practice Address - Phone:508-393-9394
Practice Address - Fax:508-393-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty