MEDICARE: LEXINGTON IMPLANT AND RESTORATIVE DENTISTRY

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	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1619446713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEXINGTON IMPLANT AND RESTORATIVE DENTISTRY

Provider Business Mailing Address
First Line	:	803 MASSACHUSETTS AVE
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-3918
Country	:	US
Telephone Number	:	781-862-8223
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 MASSACHUSETTS AVE
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420-3918
Country	:	US
Telephone Number	:	781-862-8223
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRISTA NOEL MANICKAS
Credential	:	DMD
Telephone Number	:	781-862-8223

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	11/19/2018

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