Healthcare Provider Details

I. General information

NPI: 1578366159
Provider Name (Legal Business Name): LEA ANGELO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 CENTRE ST
NEWTON MA
02459-1553
US

IV. Provider business mailing address

1280 CENTRE ST
NEWTON MA
02459-1553
US

V. Phone/Fax

Practice location:
  • Phone: 617-969-7890
  • Fax:
Mailing address:
  • Phone: 617-969-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10001431
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: