Provider Demographics
NPI:1154774404
Name:FOUR CORNERS DENTAL CARE
Entity type:Organization
Organization Name:FOUR CORNERS DENTAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOUTEVELIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-933-4144
Mailing Address - Street 1:237 LEXINGTON ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5984
Mailing Address - Country:US
Mailing Address - Phone:781-933-4144
Mailing Address - Fax:781-933-4649
Practice Address - Street 1:237 LEXINGTON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-5984
Practice Address - Country:US
Practice Address - Phone:781-933-4144
Practice Address - Fax:781-933-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15162122300000X
MA21707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty