Provider Demographics
NPI:1396062246
Name:MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION
Entity type:Organization
Organization Name:MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF, MGH DIVISION OF DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-726-1076
Mailing Address - Street 1:104 ENDICOTT ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3623
Mailing Address - Country:US
Mailing Address - Phone:978-882-6600
Mailing Address - Fax:978-882-6677
Practice Address - Street 1:104 ENDICOTT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3623
Practice Address - Country:US
Practice Address - Phone:978-882-6600
Practice Address - Fax:978-882-6677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION DBA MGH DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty