Provider Demographics
NPI:1023881570
Name:PAWTUCKET ORTHODONTICS LLC
Entity type:Organization
Organization Name:PAWTUCKET ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-678-3125
Mailing Address - Street 1:123 SCHOOL ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4270
Mailing Address - Country:US
Mailing Address - Phone:401-728-0150
Mailing Address - Fax:
Practice Address - Street 1:123 SCHOOL ST STE 3
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4270
Practice Address - Country:US
Practice Address - Phone:401-728-0150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty