Provider Demographics
NPI:1194059725
Name:METROWEST DENTAL CENTER, INC.
Entity type:Organization
Organization Name:METROWEST DENTAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DEPT
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:STJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-460-1212
Mailing Address - Street 1:116 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3811
Mailing Address - Country:US
Mailing Address - Phone:508-485-2001
Mailing Address - Fax:508-485-2201
Practice Address - Street 1:116 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3811
Practice Address - Country:US
Practice Address - Phone:508-485-2001
Practice Address - Fax:508-485-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty