Healthcare Provider Details

I. General information

NPI: 1619179827
Provider Name (Legal Business Name): LYDIA R. LEGG M.S.D, D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYDIA R. LEGG OUASSA D.D.S.

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 WEST ST FL 3
BOSTON MA
02111-1268
US

IV. Provider business mailing address

41 WEST ST FL 3
BOSTON MA
02111-1268
US

V. Phone/Fax

Practice location:
  • Phone: 617-909-6011
  • Fax:
Mailing address:
  • Phone: 617-909-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN1858884
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: