Provider Demographics
NPI:1942520101
Name:DEDE, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:DEDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BELLEVUE RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2807
Mailing Address - Country:US
Mailing Address - Phone:781-595-0311
Mailing Address - Fax:
Practice Address - Street 1:11 BELLEVUE RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2807
Practice Address - Country:US
Practice Address - Phone:781-595-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN65112164W00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide