1952385742 NPI number — DR. EDWARD HENRY FIDROCKI DDS

Table of content: DR. EDWARD HENRY FIDROCKI DDS (NPI 1952385742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952385742 NPI number — DR. EDWARD HENRY FIDROCKI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FIDROCKI
Provider First Name:
EDWARD
Provider Middle Name:
HENRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1952385742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 KNEELAND ST
Provider Second Line Business Mailing Address:
ROOM 322 A
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-0287
Provider Business Mailing Address Fax Number:
617-726-2894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 KNEELAND ST
Provider Second Line Business Practice Location Address:
ROOM 322 A
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-643-8070
Provider Business Practice Location Address Fax Number:
617-643-8122
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  15917 , 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)





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