Provider Demographics
NPI:1033224605
Name:FAWN ROSENBERG DMD FAGD PC
Entity Type:Organization
Organization Name:FAWN ROSENBERG DMD FAGD PC
Other - Org Name:FAWN ROSENBERG DMD FAGD
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAWN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, FAGD
Authorized Official - Phone:781-861-6008
Mailing Address - Street 1:922 WALTHAM STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421
Mailing Address - Country:US
Mailing Address - Phone:781-861-6008
Mailing Address - Fax:781-240-0264
Practice Address - Street 1:922 WALTHAM STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421
Practice Address - Country:US
Practice Address - Phone:781-861-6008
Practice Address - Fax:781-240-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104731223E0200X
MAMA161731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
X11765OtherBLUECROSS