Provider Demographics
NPI:1669577888
Name:PROFESSIONAL DENTAL IMAGE CORP
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL IMAGE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-924-6422
Mailing Address - Street 1:53 BIGELOW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-924-6422
Mailing Address - Fax:617-924-6422
Practice Address - Street 1:53 BIGELOW AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:617-924-6422
Practice Address - Fax:617-924-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9786139Medicaid