Provider Demographics
NPI:1114533866
Name:CDG BACK BAY LLC
Entity type:Organization
Organization Name:CDG BACK BAY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KOSTANTINA
Authorized Official - Middle Name:TINA
Authorized Official - Last Name:GIANNACOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-266-8770
Mailing Address - Street 1:400 COMMONWEALTH AVE 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-266-8770
Mailing Address - Fax:617-266-9530
Practice Address - Street 1:400 COMMONWEALTH AVE 3RD FLOOR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-266-8770
Practice Address - Fax:617-266-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental