Provider Demographics
NPI:1215175005
Name:BLACKSTONE FAMILY DENTAL
Entity type:Organization
Organization Name:BLACKSTONE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:GLASIER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-237-6260
Mailing Address - Street 1:160 WORCESTER PROVIDENCE TPKE
Mailing Address - Street 2:SUIE # 16
Mailing Address - City:SUTTON
Mailing Address - State:MA
Mailing Address - Zip Code:01590-2901
Mailing Address - Country:US
Mailing Address - Phone:312-237-6260
Mailing Address - Fax:
Practice Address - Street 1:160 WORCESTER PROVIDENCE TPKE
Practice Address - Street 2:SUIE # 16
Practice Address - City:SUTTON
Practice Address - State:MA
Practice Address - Zip Code:01590-2901
Practice Address - Country:US
Practice Address - Phone:312-237-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty