Basic Information
| Provider Information | |||||||||
| NPI: | 1467721126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 42 NORTH DENTAL CARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENTLE DENTAL JAMAICA PLAIN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 5TH AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024518759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816470772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 612 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021302552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175244400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2011 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCIALABBA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANGELO | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5615122709 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 42 NORTH DENTAL CARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.