Provider Demographics
NPI:1831358985
Name:CHILDRENS DENTAL CARE
Entity type:Organization
Organization Name:CHILDRENS DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:MRS
Authorized Official - First Name:BADRIEH
Authorized Official - Middle Name:
Authorized Official - Last Name:EDALATPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-438-0300
Mailing Address - Street 1:370 MAIN STREET
Mailing Address - Street 2:#201
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180
Mailing Address - Country:US
Mailing Address - Phone:781-438-0300
Mailing Address - Fax:781-438-0336
Practice Address - Street 1:370 MAIN STREET
Practice Address - Street 2:#201
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-438-0300
Practice Address - Fax:781-438-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA197561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12536OtherBCBS
=========19756OtherDELTA
=========19756OtherDELTA