1033224605 NPI number — FAWN ROSENBERG DMD FAGD PC

Table of content: (NPI 1033224605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033224605 NPI number — FAWN ROSENBERG DMD FAGD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAWN ROSENBERG DMD FAGD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAWN ROSENBERG DMD FAGD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033224605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 WALTHAM STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-861-6008
Provider Business Mailing Address Fax Number:
781-240-0264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 WALTHAM STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-861-6008
Provider Business Practice Location Address Fax Number:
781-240-0264
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENBERG
Authorized Official First Name:
FAWN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
781-861-6008

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  10473 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: MA16173 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: X11765 . This is a "BLUECROSS" identifier . This identifiers is of the category "OTHER".




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