Provider Demographics
NPI:1750392486
Name:CAMBRIDGE ORTHODONTICS
Entity type:Organization
Organization Name:CAMBRIDGE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:PETROSINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MMSC
Authorized Official - Phone:617-491-6800
Mailing Address - Street 1:1751 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2218
Mailing Address - Country:US
Mailing Address - Phone:617-491-6800
Mailing Address - Fax:617-491-4424
Practice Address - Street 1:1751 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2218
Practice Address - Country:US
Practice Address - Phone:617-491-6800
Practice Address - Fax:617-491-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA144601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0264482OtherINDIV MASS HEALTH NUMBER
MA9735119Medicaid