Provider Demographics
NPI:1679745988
Name:GLOUCESTER DENTAL HEALTH CENTER
Entity type:Organization
Organization Name:GLOUCESTER DENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:RICHARDSON
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:978-774-2279
Mailing Address - Street 1:99 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3742
Mailing Address - Country:US
Mailing Address - Phone:978-281-0914
Mailing Address - Fax:
Practice Address - Street 1:99 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3742
Practice Address - Country:US
Practice Address - Phone:978-281-0914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF GLOUCESTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-26
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0297569Medicare PIN