Provider Demographics
NPI:1609989235
Name:LEWIS WHARF DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LEWIS WHARF DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-227-4831
Mailing Address - Street 1:28 ATLANTIC AVE.
Mailing Address - Street 2:OFFICE 237
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110
Mailing Address - Country:US
Mailing Address - Phone:617-227-4831
Mailing Address - Fax:617-227-3174
Practice Address - Street 1:28 ATLANTIC AVE.
Practice Address - Street 2:STE. 237
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110
Practice Address - Country:US
Practice Address - Phone:617-227-4831
Practice Address - Fax:617-227-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116141223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX07015OtherBC/BS
MA185821OtherUNITED CONCORDIA