Provider Demographics
NPI:1811273378
Name:MAYNARD DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:MAYNARD DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOHEBAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-298-5281
Mailing Address - Street 1:63 GREAT RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2097
Mailing Address - Country:US
Mailing Address - Phone:978-298-5281
Mailing Address - Fax:978-298-5364
Practice Address - Street 1:63 GREAT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2097
Practice Address - Country:US
Practice Address - Phone:978-298-5281
Practice Address - Fax:978-298-5364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855167261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental