Healthcare Provider Details

I. General information

NPI: 1922210616
Provider Name (Legal Business Name): SAM W. LEVINE, D.D.S., M.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MUZZEY ST
LEXINGTON MA
02421-5224
US

IV. Provider business mailing address

18 MUZZEY ST
LEXINGTON MA
02421-5224
US

V. Phone/Fax

Practice location:
  • Phone: 781-860-9473
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21310
License Number StateMA

VIII. Authorized Official

Name: DR. SAM LEVINE
Title or Position: PRESIDENT
Credential:
Phone: 781-860-9473