Basic Information
| Provider Information | |||||||||
| NPI: | 1619066917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROCKTON NEIGHBORHOOD H. C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 MAIN ST | ||||||||
| Address2: | 200 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085842708 | ||||||||
| FaxNumber: | 5085591158 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 MAIN ST | ||||||||
| Address2: | 302 | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085591567 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COLES | ||||||||
| AuthorizedOfficialFirstName: | JULIUS | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTISRY | ||||||||
| AuthorizedOfficialTelephone: | 5085842708 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 1210420 | MA | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.