Provider Demographics
NPI:1922158732
Name:ADIB I LAKIS P.C.
Entity Type:Organization
Organization Name:ADIB I LAKIS P.C.
Other - Org Name:THE CANTON DENTAL COLLABORATIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADIB
Authorized Official - Middle Name:IBRAHIM
Authorized Official - Last Name:LAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-821-2120
Mailing Address - Street 1:95 WASHINGTON STREET
Mailing Address - Street 2:SUITE 472
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021
Mailing Address - Country:US
Mailing Address - Phone:781-821-2120
Mailing Address - Fax:781-821-2433
Practice Address - Street 1:95 WASHINGTON STREET
Practice Address - Street 2:SUITE 472
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021
Practice Address - Country:US
Practice Address - Phone:781-821-2120
Practice Address - Fax:781-821-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA183621223G0001X
MA182941223G0001X
MA175561223G0001X
MA184881223P0106X
MA185021223P0300X
MA191341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX10837OtherBLUE CROSS OF MASS
MA380796OtherHPHC