Provider Demographics
NPI:1669257317
Name:MY DENTAL WATERTOWN
Entity type:Organization
Organization Name:MY DENTAL WATERTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DESANEEDI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:740-215-8549
Mailing Address - Street 1:20 BALANCING ROCK RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-4230
Mailing Address - Country:US
Mailing Address - Phone:740-215-8549
Mailing Address - Fax:
Practice Address - Street 1:171 WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2699
Practice Address - Country:US
Practice Address - Phone:617-467-5113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental