Healthcare Provider Details

I. General information

NPI: 1427349372
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATES OF LEXINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BEDFORD ST SUITE 15
LEXINGTON MA
02420-4319
US

IV. Provider business mailing address

33 BEDFORD ST SUITE 15
LEXINGTON MA
02420-4319
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-9222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number16260
License Number StateMA

VIII. Authorized Official

Name: DR. ELISA FULTON
Title or Position: HEAD ASSOC
Credential: DMD
Phone: 781-760-4928