Provider Demographics
NPI:1063963353
Name:FITCHBURGH DENTISTRY AND BRACES PC
Entity type:Organization
Organization Name:FITCHBURGH DENTISTRY AND BRACES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:5 MOUNT ROYAL AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1981
Mailing Address - Country:US
Mailing Address - Phone:508-460-0632
Mailing Address - Fax:
Practice Address - Street 1:505 JOHN FITCH HWY
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-8403
Practice Address - Country:US
Practice Address - Phone:508-460-0632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service