Provider Demographics
NPI:1295347342
Name:RADDALL, THOMAS HEAD IV (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HEAD
Last Name:RADDALL
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:80 FENWOOD ROAD
Mailing Address - Street 2:SUITE 710
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:902-350-1717
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVENUE
Practice Address - Street 2:BOSTON CHILDREN'S HOSPITAL - DEPARTMENT OF DENTISTRY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-355-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL14399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist