Provider Demographics
NPI:1174046684
Name:POONAM SOI DMD LLC
Entity type:Organization
Organization Name:POONAM SOI DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:POONAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SOI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:206-949-7622
Mailing Address - Street 1:160 CAMBRIDGEPARK DRIVE APT 359
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140
Mailing Address - Country:US
Mailing Address - Phone:206-949-7622
Mailing Address - Fax:
Practice Address - Street 1:376 MOODY ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5204
Practice Address - Country:US
Practice Address - Phone:206-949-7622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty