Basic Information
| Provider Information | |||||||||
| NPI: | 1033233713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONGWOOD DENTAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1842 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024451930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175665445 | ||||||||
| FaxNumber: | 6177308482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1842 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024451930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175665445 | ||||||||
| FaxNumber: | 6177308482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KILADJIAN | ||||||||
| AuthorizedOfficialFirstName: | BERDJ | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6175665445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223E0200X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0106X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Pathology | 1223P0300X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0700X | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 124Q00000X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 126800000X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 126900000X | MA | X | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Laboratory Technician |
No ID Information.