Provider Demographics
NPI:1356563316
Name:SOUTH BOSTON DENTAL ASSOCIATES
Entity type:Organization
Organization Name:SOUTH BOSTON DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-268-1030
Mailing Address - Street 1:29 FARRAGUT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1714
Mailing Address - Country:US
Mailing Address - Phone:617-268-1030
Mailing Address - Fax:
Practice Address - Street 1:29 FARRAGUT RD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1714
Practice Address - Country:US
Practice Address - Phone:617-268-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
X10143OtherBLUE CROSS BLUE SHIELD