1104869809 NPI number — DR. MARILYN S LYONS DMD, MMS

Table of content: THERESE MARIE KIM (NPI 1053839266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104869809 NPI number — DR. MARILYN S LYONS DMD, MMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYONS
Provider First Name:
MARILYN
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD, MMS
Provider Gender Code:
F

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:
1104869809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 GILCREAST ROAD, #2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDONDERRY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-425-2307
Provider Business Mailing Address Fax Number:
603-437-8190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 GILCREAST ROAD
Provider Second Line Business Practice Location Address:
#2000
Provider Business Practice Location Address City Name:
LONDONDERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-425-2307
Provider Business Practice Location Address Fax Number:
603-437-8190
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  1844 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223E0200X , with the licence number: 13970 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: X12135 . This is a "BC/BS OF MA PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: X12134 . This is a "BC/BS OF MA PROVIDER #" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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