Provider Demographics
NPI:1710084777
Name:DEVITO, LOUIS JR (DMD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:DEVITO
Suffix:JR
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 1:385 BROADWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3033
Mailing Address - Country:US
Mailing Address - Phone:781-289-8080
Mailing Address - Fax:781-286-6860
Practice Address - Street 1:385 BROADWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3033
Practice Address - Country:US
Practice Address - Phone:781-289-8080
Practice Address - Fax:781-286-6860
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist