Provider Demographics
NPI:1407824741
Name:THACH, LEE W (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:W
Last Name:THACH
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 1:186 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5222
Mailing Address - Country:US
Mailing Address - Phone:617-389-2112
Mailing Address - Fax:617-389-5885
Practice Address - Street 1:186 ELM ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5222
Practice Address - Country:US
Practice Address - Phone:617-389-2112
Practice Address - Fax:617-389-5885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203220Medicaid