Provider Demographics
NPI:1184284549
Name:SOUTHBRIDGE DENTAL LLC
Entity type:Organization
Organization Name:SOUTHBRIDGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDIVARI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-552-1567
Mailing Address - Street 1:305 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3726
Mailing Address - Country:US
Mailing Address - Phone:508-765-0880
Mailing Address - Fax:
Practice Address - Street 1:305 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3726
Practice Address - Country:US
Practice Address - Phone:508-765-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3071228Medicaid