Provider Demographics
NPI:1700148301
Name:APOLLO DENTAL ASS.
Entity Type:Organization
Organization Name:APOLLO DENTAL ASS.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEUTRANG
Authorized Official - Middle Name:
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-354-1678
Mailing Address - Street 1:940 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1218
Mailing Address - Country:US
Mailing Address - Phone:617-354-1678
Mailing Address - Fax:617-354-2927
Practice Address - Street 1:940 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1218
Practice Address - Country:US
Practice Address - Phone:617-354-1678
Practice Address - Fax:617-354-2927
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APOLLO DENTAL ASS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703195Medicaid