Provider Demographics
NPI:1306276969
Name:GROTON WELLNESS FAMILY DENTISTRY,LLC
Entity type:Organization
Organization Name:GROTON WELLNESS FAMILY DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:G.ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-449-9919
Mailing Address - Street 1:495 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450-4253
Mailing Address - Country:US
Mailing Address - Phone:978-449-9919
Mailing Address - Fax:978-449-9929
Practice Address - Street 1:495 MAIN ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450-4253
Practice Address - Country:US
Practice Address - Phone:978-449-9919
Practice Address - Fax:978-449-9929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13901261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental