Provider Demographics
NPI:1831534379
Name:SALEM PEDIATRIC DENTAL & ORTHODONTIC ASSOCIATES
Entity type:Organization
Organization Name:SALEM PEDIATRIC DENTAL & ORTHODONTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-745-7363
Mailing Address - Street 1:116 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2723
Mailing Address - Country:US
Mailing Address - Phone:978-745-7363
Mailing Address - Fax:978-745-8470
Practice Address - Street 1:116 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2723
Practice Address - Country:US
Practice Address - Phone:978-745-7363
Practice Address - Fax:978-745-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty