Healthcare Provider Details

I. General information

NPI: 1619446713
Provider Name (Legal Business Name): LEXINGTON IMPLANT AND RESTORATIVE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 MASSACHUSETTS AVE
LEXINGTON MA
02420-3918
US

IV. Provider business mailing address

803 MASSACHUSETTS AVE
LEXINGTON MA
02420-3918
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-8223
  • Fax:
Mailing address:
  • Phone: 781-862-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTA NOEL MANICKAS
Title or Position: OWNER
Credential: DMD
Phone: 781-862-8223