Provider Demographics
NPI:1871765966
Name:WOLLASTON DENTAL CARE, INC
Entity type:Organization
Organization Name:WOLLASTON DENTAL CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-984-5888
Mailing Address - Street 1:688 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-2814
Mailing Address - Country:US
Mailing Address - Phone:617-984-5888
Mailing Address - Fax:617-984-5822
Practice Address - Street 1:688 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-2814
Practice Address - Country:US
Practice Address - Phone:617-984-5888
Practice Address - Fax:617-984-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20147122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11526OtherBLUE CROSS BLUE SHIELD