Provider Demographics
NPI:1902313570
Name:HANOVER PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:HANOVER PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LINDHOLM
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:781-312-0444
Mailing Address - Street 1:648 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-2386
Mailing Address - Country:US
Mailing Address - Phone:781-312-0444
Mailing Address - Fax:
Practice Address - Street 1:648 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2386
Practice Address - Country:US
Practice Address - Phone:781-312-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18556981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty