Provider Demographics
NPI:1104317494
Name:REILLY-LAKE, PAULINE P (DMD)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:P
Last Name:REILLY-LAKE
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 1:18 MOUNT PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-2116
Mailing Address - Country:US
Mailing Address - Phone:978-790-8278
Mailing Address - Fax:
Practice Address - Street 1:16 HAVERHILL ST STE 1
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3000
Practice Address - Country:US
Practice Address - Phone:978-699-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL13614204E00000X
MADN18582291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery