Provider Demographics
NPI:1649772260
Name:MARIE B JEAN-MARY DMD LLC
Entity type:Organization
Organization Name:MARIE B JEAN-MARY DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:JEAN-MARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-868-2545
Mailing Address - Street 1:1058 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1407
Mailing Address - Country:US
Mailing Address - Phone:617-868-2545
Mailing Address - Fax:
Practice Address - Street 1:1058 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1407
Practice Address - Country:US
Practice Address - Phone:617-868-2545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18588261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110100017AMedicaid