Provider Demographics
NPI:1053893115
Name:SOMERVILLE DENTISTRY AND BRACES, P.C.
Entity type:Organization
Organization Name:SOMERVILLE DENTISTRY AND BRACES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:5 MOUNT ROYAL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1900
Mailing Address - Country:US
Mailing Address - Phone:508-723-0725
Mailing Address - Fax:508-872-0781
Practice Address - Street 1:5 MIDDLESEX AVE STE 305
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1110
Practice Address - Country:US
Practice Address - Phone:508-872-3072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN202091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN20209OtherSTATE LICENSE