Provider Demographics
NPI:1538408745
Name:ASSEMBLY SQUARE FAMILY DENTAL
Entity type:Organization
Organization Name:ASSEMBLY SQUARE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANJEEVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-764-1781
Mailing Address - Street 1:5 MIDDLESEX AVE
Mailing Address - Street 2:SUITE 305, 3RD FLOOR
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1102
Mailing Address - Country:US
Mailing Address - Phone:617-764-1781
Mailing Address - Fax:617-764-5649
Practice Address - Street 1:5 MIDDLESEX AVE
Practice Address - Street 2:SUITE 305, 3RD FLOOR
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1102
Practice Address - Country:US
Practice Address - Phone:617-764-1781
Practice Address - Fax:617-764-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18550581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty