Provider Demographics
NPI:1538278510
Name:BROOKLINE PERIODENTAL ASSOC
Entity type:Organization
Organization Name:BROOKLINE PERIODENTAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MENTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-232-8222
Mailing Address - Street 1:1443 BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:617-232-8222
Mailing Address - Fax:617-277-2027
Practice Address - Street 1:1443 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4707
Practice Address - Country:US
Practice Address - Phone:617-232-8222
Practice Address - Fax:617-277-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty