Provider Demographics
NPI:1457375107
Name:COMMONWEALTH ORAL & MAXILLOFACIAL SURGICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:COMMONWEALTH ORAL & MAXILLOFACIAL SURGICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:LECHTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-492-8700
Mailing Address - Street 1:2353 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-1252
Mailing Address - Country:US
Mailing Address - Phone:617-492-8700
Mailing Address - Fax:617-492-0698
Practice Address - Street 1:2353 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1252
Practice Address - Country:US
Practice Address - Phone:617-492-8700
Practice Address - Fax:617-492-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA108231223S0112X
MA154411223S0112X
MA204621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX03883Medicare ID - Type Unspecified