1396120689 NPI number — LENNON STREET DENTAL ASSOCIATES PLLC

Table of content: (NPI 1396120689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396120689 NPI number — LENNON STREET DENTAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LENNON STREET DENTAL ASSOCIATES PLLC
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:
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NPI Number Information

NPI Number:
1396120689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 LENNON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDNER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01440-3907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-632-5502
Provider Business Mailing Address Fax Number:
978-632-0964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 LENNON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDNER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01440-3907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-632-5502
Provider Business Practice Location Address Fax Number:
978-632-0964
Provider Enumeration Date:
07/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
APOTHEKER
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
978-632-5502

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  13152 , 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)





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