Provider Demographics
NPI:1740061613
Name:SOMERVILLE PEDIATRIC DENTISTRY PC
Entity type:Organization
Organization Name:SOMERVILLE PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:W
Authorized Official - Last Name:THACH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-227-2421
Mailing Address - Street 1:100 EVERETT AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2374
Mailing Address - Country:US
Mailing Address - Phone:617-389-2112
Mailing Address - Fax:617-389-5885
Practice Address - Street 1:51 CROSS ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-3244
Practice Address - Country:US
Practice Address - Phone:617-227-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty