1417204884 NPI number — LUX DENTAL FOR KIDS

Table of content: (NPI 1417204884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417204884 NPI number — LUX DENTAL FOR KIDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUX DENTAL FOR KIDS
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:
6
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:
1417204884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-5834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-756-1928
Provider Business Mailing Address Fax Number:
206-203-2845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 BROADWAY
Provider Second Line Business Practice Location Address:
ROOM E215
Provider Business Practice Location Address City Name:
SAUGUS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01906-4177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-558-5092
Provider Business Practice Location Address Fax Number:
206-203-2845
Provider Enumeration Date:
08/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ABDULWAHEED
Authorized Official First Name:
ABDULLAIBRAHIM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-558-5092

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  20827 , 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)





Copyright © 2007-2025 www.npivalidator.com