Provider Demographics
NPI:1194260588
Name:MANSFIELD PERIODONTICS AND DENTAL IMPLANTS, PLLC
Entity type:Organization
Organization Name:MANSFIELD PERIODONTICS AND DENTAL IMPLANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-543-9292
Mailing Address - Street 1:100 COPELAND DR
Mailing Address - Street 2:UNIT 3
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1245
Mailing Address - Country:US
Mailing Address - Phone:508-543-9292
Mailing Address - Fax:508-339-1919
Practice Address - Street 1:100 COPELAND DR
Practice Address - Street 2:UNIT 3
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1245
Practice Address - Country:US
Practice Address - Phone:508-543-9292
Practice Address - Fax:508-339-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21803261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental