Provider Demographics
NPI:1932849593
Name:VANDOREN, EMILY JUNE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JUNE
Last Name:VANDOREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JUNE
Other - Last Name:VAN DOREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:188 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program