Provider Demographics
NPI:1699277368
Name:BEACON DENTAL HEALTH PC
Entity type:Organization
Organization Name:BEACON DENTAL HEALTH PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RISHI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-418-6940
Mailing Address - Street 1:198 TREMONT ST STE 436
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-4705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:399 W CENTER ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1623
Practice Address - Country:US
Practice Address - Phone:617-418-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON DENTAL HEALTH PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN21699261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental