Provider Demographics
NPI:1649799438
Name:DAVIS SQUARE DENTAL SPECIALISTS LLC
Entity type:Organization
Organization Name:DAVIS SQUARE DENTAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-591-9999
Mailing Address - Street 1:30 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1914
Mailing Address - Country:US
Mailing Address - Phone:617-591-9999
Mailing Address - Fax:
Practice Address - Street 1:509 CONCORD STREET
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702
Practice Address - Country:US
Practice Address - Phone:508-879-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN204161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty