Provider Demographics
NPI:1386092807
Name:HALLMARK DENTAL EVERETT
Entity type:Organization
Organization Name:HALLMARK DENTAL EVERETT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KROTHAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-223-1652
Mailing Address - Street 1:551 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3737
Practice Address - Country:US
Practice Address - Phone:617-223-1652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty