Provider Demographics
NPI:1902929961
Name:MOUNT IDA COLLEGE
Entity Type:Organization
Organization Name:MOUNT IDA COLLEGE
Other - Org Name:MOUNT IDA COLLEGE DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERVISING DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-928-7360
Mailing Address - Street 1:777 DEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3323
Mailing Address - Country:US
Mailing Address - Phone:617-928-7360
Mailing Address - Fax:617-928-7030
Practice Address - Street 1:777 DEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3323
Practice Address - Country:US
Practice Address - Phone:617-928-7360
Practice Address - Fax:617-928-7030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0297658Medicaid