Provider Demographics
NPI:1265439657
Name:MITTELMAN, DREW M (DMD)
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:M
Last Name:MITTELMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02027-9120
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-278-5667
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-278-5667
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA125691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
12569OtherDELTA DENTAL
X04083OtherDENTAL BLUE
X04083OtherFIRST SENIORITY
X04083OtherHARVARD PILGRIM PPO
X04083OtherHARVARD/PILGRIM
X04083OtherHARVARD PILGRIM POS
0016778OtherNEIGHBORHOOD HEALTH PLAN
X04083OtherFIRST SENIORITY