Basic Information
Provider Information | |||||||||
NPI: | 1639192271 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIN | ||||||||
FirstName: | RODERICK | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 326 NICHOLS ROAD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | MA | ||||||||
PostalCode: | 01420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788788516 | ||||||||
FaxNumber: | 9788788418 | ||||||||
Practice Location | |||||||||
Address1: | 326 NICHOLS ROAD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | MA | ||||||||
PostalCode: | 01420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788788100 | ||||||||
FaxNumber: | 9788788326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 08/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 8888 | MA | N |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 8883 | MA | Y |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
ID | Type | State | Issuer | Description | 1319833 | 05 | MA |   | MEDICAID | 221845 | 01 |   | UGS | OTHER | X02562 | 01 | MA | BS OF MA | OTHER |