Provider Demographics
NPI:1104443936
Name:HEIDEMANN PAGANINI, LARISSA (DMD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:HEIDEMANN PAGANINI
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 1:215 PARK ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2727
Mailing Address - Country:US
Mailing Address - Phone:617-767-9230
Mailing Address - Fax:
Practice Address - Street 1:128 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-3201
Practice Address - Country:US
Practice Address - Phone:617-764-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18587101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice