Healthcare Provider Details

I. General information

NPI: 1548861339
Provider Name (Legal Business Name): LEXINGTON DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BEDFORD ST STE 110
LEXINGTON MA
02420-4320
US

IV. Provider business mailing address

35 BEDFORD ST STE 16
LEXINGTON MA
02420-4440
US

V. Phone/Fax

Practice location:
  • Phone: 781-674-9995
  • Fax: 978-922-6727
Mailing address:
  • Phone: 781-863-0096
  • Fax: 978-922-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LORRAINE MATHEUS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 781-562-0457