Provider Demographics
NPI:1992331755
Name:MEDFORD DENTAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:MEDFORD DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPAPETROS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-754-4545
Mailing Address - Street 1:101 MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4530
Mailing Address - Country:US
Mailing Address - Phone:781-395-5545
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4530
Practice Address - Country:US
Practice Address - Phone:781-395-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty