Provider Demographics
NPI:1033518428
Name:LEVESQUE, DEREK M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:M
Last Name:LEVESQUE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WHALON ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-7138
Mailing Address - Country:US
Mailing Address - Phone:978-435-6919
Mailing Address - Fax:
Practice Address - Street 1:26 WHALON ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7138
Practice Address - Country:US
Practice Address - Phone:978-435-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18566561223G0001X
NH040541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice