Healthcare Provider Details

I. General information

NPI: 1265447965
Provider Name (Legal Business Name): EDWARD T LAHEY III MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST FL 5
BOSTON MA
02111-1529
US

IV. Provider business mailing address

1 KNEELAND ST FL 5
BOSTON MA
02111-1529
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6515
  • Fax: 617-636-6809
Mailing address:
  • Phone: 617-636-6515
  • Fax: 617-636-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN21157
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number230038
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: