Provider Demographics
NPI:1902679061
Name:IDG BOSTON HIGH STREET DENTAL PC
Entity Type:Organization
Organization Name:IDG BOSTON HIGH STREET DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEEJEONG
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-485-4752
Mailing Address - Street 1:10 HIGH ST STE 333
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1672
Mailing Address - Country:US
Mailing Address - Phone:617-482-2500
Mailing Address - Fax:
Practice Address - Street 1:10 HIGH ST STE 333
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1672
Practice Address - Country:US
Practice Address - Phone:617-482-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty