Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN1858229 | MA |
Y | 213EG0000X | General Practice | DN1858229 | MA |
N | 204E00000X | Oral & Maxillofacial Surgeon | DL13614 | MA |
NPI | 1104317494 |
---|---|
Provider Name | Pauline P Reilly-Lake |
First Address | Ipswich, MA 01938-2116 |
Second Address | Newburyport, MA 01950-3961 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2018 |
Last Update Date | 27/01/2022 |