Healthcare Provider Details

I. General information

NPI: 1194889766
Provider Name (Legal Business Name): MAYMUDMD, RALPHLEWIS,DMD,LILILIN, DMDLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WINTHROP AVE
LAWRENCE MA
01843-3840
US

IV. Provider business mailing address

160 WINTHROP AVE
LAWRENCE MA
01843-3840
US

V. Phone/Fax

Practice location:
  • Phone: 978-725-0072
  • Fax: 978-725-6699
Mailing address:
  • Phone: 978-725-0072
  • Fax: 978-725-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14926
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number17629
License Number StateMA

VIII. Authorized Official

Name: DR. MAY MU
Title or Position: OWNER
Credential:
Phone: 978-725-0072