Provider Demographics
NPI:1831275627
Name:ANTUN LAGO, REEM (DMD)
Entity type:Individual
Prefix:DR
First Name:REEM
Middle Name:
Last Name:ANTUN LAGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 TRAPELO RD APT 4
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-4875
Mailing Address - Country:US
Mailing Address - Phone:781-373-1171
Mailing Address - Fax:
Practice Address - Street 1:24 LYMAN ST STE 240
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1483
Practice Address - Country:US
Practice Address - Phone:508-366-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAANX11834OtherBCBS MS
RIMOOX11834OtherBCBS RI