Provider Demographics
NPI:1033326087
Name:LAGO, FEDERICO FABIAN (DMD)
Entity Type:Individual
Prefix:
First Name:FEDERICO
Middle Name:FABIAN
Last Name:LAGO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 TRAPELO RD APT 4
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-4875
Mailing Address - Country:US
Mailing Address - Phone:917-626-1105
Mailing Address - Fax:
Practice Address - Street 1:1 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2200
Practice Address - Country:US
Practice Address - Phone:978-535-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry