Provider Demographics
NPI:1831390368
Name:CITIDENTAL, LLC
Entity type:Organization
Organization Name:CITIDENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADIVI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-723-6300
Mailing Address - Street 1:63 COURT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2109
Mailing Address - Country:US
Mailing Address - Phone:617-723-6300
Mailing Address - Fax:617-723-1717
Practice Address - Street 1:63 COURT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2109
Practice Address - Country:US
Practice Address - Phone:617-723-6300
Practice Address - Fax:617-723-1717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX12378OtherBLUECROSS BLUESHIELD
PA1725478OtherUNITED CONCORDIA