Provider Demographics
NPI:1619179827
Name:LEGG, LYDIA R (DDS)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:R
Last Name:LEGG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:LYDIA
Other - Middle Name:R
Other - Last Name:LEGG OUASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:243 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3096
Mailing Address - Country:US
Mailing Address - Phone:617-573-3489
Mailing Address - Fax:
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3096
Practice Address - Country:US
Practice Address - Phone:617-573-3489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18588841223P0700X
WV37661223G0001X
NY0560571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401412938OtherLICENSE
WV3766OtherSTATE LICENSE
NY056057OtherLICENSE