Provider Demographics
NPI:1588928147
Name:SOUTHEASTERN DENTAL CARE, PC
Entity type:Organization
Organization Name:SOUTHEASTERN DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINH-PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-947-5717
Mailing Address - Street 1:336 BEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-2136
Mailing Address - Country:US
Mailing Address - Phone:508-947-5717
Mailing Address - Fax:508-947-8405
Practice Address - Street 1:336 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-2136
Practice Address - Country:US
Practice Address - Phone:508-947-5717
Practice Address - Fax:508-947-8405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110068471AMedicaid