Provider Demographics
NPI:1710573910
Name:MEDELLA DENTAL, PLLC
Entity type:Organization
Organization Name:MEDELLA DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-588-6964
Mailing Address - Street 1:1034 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1534
Mailing Address - Country:US
Mailing Address - Phone:508-588-6964
Mailing Address - Fax:
Practice Address - Street 1:1034 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1534
Practice Address - Country:US
Practice Address - Phone:508-588-6964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-12
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1700282670Medicaid