Provider Demographics
NPI:1669767117
Name:PEDIATRIC DENTAL GROUP INC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSIOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:116 MAIN ST
Mailing Address - Street 2:SUITE1
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3811
Mailing Address - Country:US
Mailing Address - Phone:508-485-2001
Mailing Address - Fax:508-485-2201
Practice Address - Street 1:116 MAIN ST
Practice Address - Street 2:SUITE1
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3811
Practice Address - Country:US
Practice Address - Phone:508-485-2001
Practice Address - Fax:508-485-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA125811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty