Provider Demographics
NPI:1588947428
Name:PROCARE DENTAL INC
Entity type:Organization
Organization Name:PROCARE DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANG
Authorized Official - Middle Name:JIN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-743-7888
Mailing Address - Street 1:51 MILL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1641
Mailing Address - Country:US
Mailing Address - Phone:508-743-7888
Mailing Address - Fax:888-594-4555
Practice Address - Street 1:51 MILL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1641
Practice Address - Country:US
Practice Address - Phone:508-743-7888
Practice Address - Fax:888-594-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21084302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9762540Medicaid