Provider Demographics
NPI:1730737545
Name:SOUTHWOODS BOULEVARD DENTAL, P.C.
Entity type:Organization
Organization Name:SOUTHWOODS BOULEVARD DENTAL, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MAYLOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-874-8198
Mailing Address - Street 1:330 WHITNEY AVE STE 740
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2789
Mailing Address - Country:US
Mailing Address - Phone:413-382-7022
Mailing Address - Fax:
Practice Address - Street 1:7 SOUTHWOODS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2526
Practice Address - Country:US
Practice Address - Phone:518-445-2505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWOODS BOULEVARD DENTAL, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-27
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty