Provider Demographics
NPI:1770108656
Name:NEDG BOSTON
Entity type:Organization
Organization Name:NEDG BOSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GOKULAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THIAGARAJAH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-962-2332
Mailing Address - Street 1:257 TURNPIKE RD STE 330
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1791
Mailing Address - Country:US
Mailing Address - Phone:508-281-6464
Mailing Address - Fax:508-281-6677
Practice Address - Street 1:1 MILK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-5413
Practice Address - Country:US
Practice Address - Phone:508-281-6464
Practice Address - Fax:508-281-6677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1801936075OtherDELTA DENTAL OF MA