Provider Demographics
NPI:1265583199
Name:MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION
Entity type:Organization
Organization Name:MASSACHUSETTS GENERAL PHYSICIANS ORGANIZATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MGH DENTAL GROUP
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-726-1076
Mailing Address - Street 1:165 CAMBRIDGE ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2783
Mailing Address - Country:US
Mailing Address - Phone:617-726-1076
Mailing Address - Fax:617-724-6681
Practice Address - Street 1:165 CAMBRIDGE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2783
Practice Address - Country:US
Practice Address - Phone:617-726-1076
Practice Address - Fax:617-724-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1364OtherDELTA DENTAL SPECIALIST
MA774OtherDELTA DENTAL GROUP NUMBER
MA9762779Medicaid