Provider Demographics
NPI:1730544743
Name:PEDIATRIC DENTAL PROFESSIONALS LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL PROFESSIONALS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PEDRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JAVEDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAAPD
Authorized Official - Phone:617-393-5437
Mailing Address - Street 1:575 MOUNT AUBURN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4627
Mailing Address - Country:US
Mailing Address - Phone:617-393-5437
Mailing Address - Fax:
Practice Address - Street 1:391 LYNN WAY
Practice Address - Street 2:BLDG A
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901
Practice Address - Country:US
Practice Address - Phone:617-393-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN-18556171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty