Provider Demographics
NPI:1770755514
Name:ATLANTIC DENTAL
Entity type:Organization
Organization Name:ATLANTIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-599-3553
Mailing Address - Street 1:153 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4835
Mailing Address - Country:US
Mailing Address - Phone:781-599-3553
Mailing Address - Fax:781-599-5959
Practice Address - Street 1:153 LEWIS ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4835
Practice Address - Country:US
Practice Address - Phone:781-599-3553
Practice Address - Fax:781-599-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0201421Medicaid