Provider Demographics
NPI:1912058421
Name:MAVERICK FAMILY DENTAL PC
Entity Type:Organization
Organization Name:MAVERICK FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-567-3800
Mailing Address - Street 1:45 MAVERICK SQ
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2312
Mailing Address - Country:US
Mailing Address - Phone:617-567-3800
Mailing Address - Fax:617-567-3802
Practice Address - Street 1:45 MAVERICK SQ
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2312
Practice Address - Country:US
Practice Address - Phone:617-567-3800
Practice Address - Fax:617-567-3802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203980Medicaid