Basic Information
Provider Information | |||||||||
NPI: | 1881715332 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARBOR HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELLEN JONES COMMUNITY DENTAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1135 MORTON STREET | ||||||||
Address2: |   | ||||||||
City: | MATTAPAN | ||||||||
State: | MA | ||||||||
PostalCode: | 021262834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6175332300 | ||||||||
FaxNumber: | 6175332301 | ||||||||
Practice Location | |||||||||
Address1: | 516 ROUTE 134 STE 12 | ||||||||
Address2: |   | ||||||||
City: | SOUTH DENNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026603430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084307710 | ||||||||
FaxNumber: | 5084301599 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2007 | ||||||||
LastUpdateDate: | 06/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 6175332300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.