1609989235 NPI number — LEWIS WHARF DENTAL ASSOCIATES

Table of content: (NPI 1609989235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609989235 NPI number — LEWIS WHARF DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEWIS WHARF DENTAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609989235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 ATLANTIC AVE.
Provider Second Line Business Mailing Address:
OFFICE 237
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-227-4831
Provider Business Mailing Address Fax Number:
617-227-3174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 ATLANTIC AVE.
Provider Second Line Business Practice Location Address:
STE. 237
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-227-4831
Provider Business Practice Location Address Fax Number:
617-227-3174
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANESS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
617-227-4831

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  11614 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: X07015 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 185821 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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