Provider Demographics
NPI:1053517037
Name:PROSTHODONTICS, P.C.
Entity type:Organization
Organization Name:PROSTHODONTICS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY-LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:COURCELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-6726
Mailing Address - Street 1:16 ENON ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1116
Mailing Address - Country:US
Mailing Address - Phone:978-922-6726
Mailing Address - Fax:978-922-6727
Practice Address - Street 1:16 ENON ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1116
Practice Address - Country:US
Practice Address - Phone:978-922-6726
Practice Address - Fax:978-922-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175591223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty