Provider Demographics
NPI:1215081625
Name:COMMONWEALTH MOBILE ORAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:COMMONWEALTH MOBILE ORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MPH,CCHP
Authorized Official - Phone:508-947-0111
Mailing Address - Street 1:12 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1663
Mailing Address - Country:US
Mailing Address - Phone:508-947-0111
Mailing Address - Fax:508-743-7827
Practice Address - Street 1:12 COLLEEN DR
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1663
Practice Address - Country:US
Practice Address - Phone:508-947-0111
Practice Address - Fax:508-743-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9756892Medicaid
NY01730905Medicaid
NY01761953Medicaid
NH30010445Medicaid
MA0245844Medicaid
NH30010446Medicaid