Provider Demographics
NPI:1083054001
Name:KIRTANE, ROHAN SHANTANU (DMD, AEGD)
Entity Type:Individual
Prefix:DR
First Name:ROHAN
Middle Name:SHANTANU
Last Name:KIRTANE
Suffix:
Gender:M
Credentials:DMD, AEGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 MASSACHUSETTS AVE
Mailing Address - Street 2:APARTMENT 1A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4029
Mailing Address - Country:US
Mailing Address - Phone:949-678-9555
Mailing Address - Fax:
Practice Address - Street 1:45 NEWPORT AVENUE
Practice Address - Street 2:ASPENDENTAL
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-9902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL119491223G0001X
MADN18565661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice