Provider Demographics
NPI:1720431919
Name:COPLEY DENTAL WEST
Entity Type:Organization
Organization Name:COPLEY DENTAL WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BADAOUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-415-8989
Mailing Address - Street 1:17 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-2213
Mailing Address - Country:US
Mailing Address - Phone:617-415-8989
Mailing Address - Fax:
Practice Address - Street 1:17 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-2213
Practice Address - Country:US
Practice Address - Phone:617-415-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17489261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental