Provider Demographics
NPI:1730398082
Name:CENTER FOR COSMETIC DENTISTRY
Entity type:Organization
Organization Name:CENTER FOR COSMETIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PEYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADIVI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-335-4900
Mailing Address - Street 1:561 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1817
Mailing Address - Country:US
Mailing Address - Phone:781-335-4900
Mailing Address - Fax:781-335-6953
Practice Address - Street 1:561 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1817
Practice Address - Country:US
Practice Address - Phone:781-335-4900
Practice Address - Fax:781-335-6953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty