MEDICARE: COURTNEY LAVIGNE DMD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN1856353	MA

General Provider Information

NPI Number	:	1326453853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COURTNEY LAVIGNE DMD LLC

Provider Business Mailing Address
First Line	:	109 ANDREW AVE
Second Line	:	SUITE 202
City	:	WAYLAND
State	:	MA
Zip	:	01778-3156
Country	:	US
Telephone Number	:	508-358-2122
Fax Number	:	508-358-9522

Provider Business Practice Location Address
First Line	:	109 ANDREW AVE
Second Line	:	SUITE 202
City	:	WAYLAND
State	:	MA
Zip	:	01778-3156
Country	:	US
Telephone Number	:	508-358-2122
Fax Number	:	508-358-9522

Authorized Official
Title or Position	:	DENTIST, OWNER
Name	:	DR. COURTNEY L LAVIGNE
Credential	:	DMD
Telephone Number	:	508-358-2122

Provider Enumeration Date	:	06/23/2014
Last Update Date	:	06/23/2014

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