Provider Demographics
NPI:1750555181
Name:NORTH SHORE PEDIATRIC DENTAL ASSOCIATES
Entity type:Organization
Organization Name:NORTH SHORE PEDIATRIC DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPANELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-236-1188
Mailing Address - Street 1:900 CUMMINGS CTR
Mailing Address - Street 2:SUITE 116-T
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6198
Mailing Address - Country:US
Mailing Address - Phone:978-236-1188
Mailing Address - Fax:
Practice Address - Street 1:900 CUMMINGS CTR
Practice Address - Street 2:SUITE 116-T
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6198
Practice Address - Country:US
Practice Address - Phone:978-236-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19450261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental