Provider Demographics
NPI:1063732477
Name:CONCORDDENTAL IMPLANTS &PERIODONTICS
Entity type:Organization
Organization Name:CONCORDDENTAL IMPLANTS &PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-369-4611
Mailing Address - Street 1:290 BAKER AVE
Mailing Address - Street 2:SUITE205
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2189
Mailing Address - Country:US
Mailing Address - Phone:978-369-4611
Mailing Address - Fax:978-369-4622
Practice Address - Street 1:290 BAKER AVE
Practice Address - Street 2:S205
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2189
Practice Address - Country:US
Practice Address - Phone:978-369-4611
Practice Address - Fax:978-369-4622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty