Provider Demographics
NPI:1255569315
Name:NEELY, MARTHA LUCIA (DMD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:LUCIA
Last Name:NEELY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARTHA
Other - Middle Name:LUCIA
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:60 SAGAMORE ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-2537
Mailing Address - Country:US
Mailing Address - Phone:781-853-9992
Mailing Address - Fax:
Practice Address - Street 1:119 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1274
Practice Address - Country:US
Practice Address - Phone:978-345-7988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10203122300000X
MADN18563481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist