Provider Demographics
NPI:1902090632
Name:APOLLO DENTAL ASS.
Entity Type:Organization
Organization Name:APOLLO DENTAL ASS.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEUTRANG
Authorized Official - Middle Name:
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-354-1678
Mailing Address - Street 1:413 MASS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4102
Mailing Address - Country:US
Mailing Address - Phone:617-354-1678
Mailing Address - Fax:617-534-2927
Practice Address - Street 1:413 MASS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4102
Practice Address - Country:US
Practice Address - Phone:617-354-1678
Practice Address - Fax:617-534-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703195Medicaid