Provider Demographics
NPI:1447700497
Name:PEDIATRIC DENTAL GROUP
Entity type:Organization
Organization Name:PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:5 MOUNT ROYAL AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1981
Mailing Address - Country:US
Mailing Address - Phone:508-872-3325
Mailing Address - Fax:508-872-0781
Practice Address - Street 1:1 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1662
Practice Address - Country:US
Practice Address - Phone:508-473-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service