Provider Demographics
NPI:1902636871
Name:SOMERVILLE AND MEDFORD ORTHODONTIC ASSOCIATES
Entity type:Organization
Organization Name:SOMERVILLE AND MEDFORD ORTHODONTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-284-6474
Mailing Address - Street 1:474 BROADWAY APT 110
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-2630
Mailing Address - Country:US
Mailing Address - Phone:617-284-6474
Mailing Address - Fax:
Practice Address - Street 1:474 BROADWAY APT 110
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-2630
Practice Address - Country:US
Practice Address - Phone:617-284-6474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty