Provider Demographics
NPI:1639264435
Name:COPPE, MICHAEL RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:COPPE
Suffix:
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 1:21 MUZZEY ST STE 6
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5259
Mailing Address - Country:US
Mailing Address - Phone:781-861-6120
Mailing Address - Fax:781-861-7856
Practice Address - Street 1:21 MUZZEY ST STE 6
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5259
Practice Address - Country:US
Practice Address - Phone:781-861-6120
Practice Address - Fax:781-861-7856
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0207772Medicaid
MA524035OtherTRICARE - TDP
MA380040OtherHARVARD PILGRIM HEALTH CA
MAX12381OtherBLUE CROSS BLUE SHIELD