Provider Demographics
NPI:1124484001
Name:FIRST IMPRESSION DENTAL, PLLC
Entity type:Organization
Organization Name:FIRST IMPRESSION DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:GRIGORY
Authorized Official - Last Name:MERZON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-207-8667
Mailing Address - Street 1:1751 MASSACHUSETTS AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2218
Mailing Address - Country:US
Mailing Address - Phone:617-207-8667
Mailing Address - Fax:
Practice Address - Street 1:1751 MASSACHUSETTS AVE FL 1
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2218
Practice Address - Country:US
Practice Address - Phone:617-207-8667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1258907261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental