Provider Demographics
NPI:1790093490
Name:WESTON PEDIATRIC DENTAL PC
Entity Type:Organization
Organization Name:WESTON PEDIATRIC DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTUN LAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-893-3003
Mailing Address - Street 1:450 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MA
Mailing Address - Zip Code:02493-1529
Mailing Address - Country:US
Mailing Address - Phone:781-893-3003
Mailing Address - Fax:
Practice Address - Street 1:450 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MA
Practice Address - Zip Code:02493-1529
Practice Address - Country:US
Practice Address - Phone:781-893-3003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122300000X
MA207821223P0221X
MA188401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty