Provider Demographics
NPI:1205179421
Name:ICYDA, ROSS USA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:USA
Last Name:ICYDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CAMBRIDGE ST
Mailing Address - Street 2:STE 401
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2750
Mailing Address - Country:US
Mailing Address - Phone:617-335-8646
Mailing Address - Fax:
Practice Address - Street 1:165 CAMBRIDGE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2783
Practice Address - Country:US
Practice Address - Phone:617-726-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9790122300000X
FLDN 19965122300000X
MADN1856767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist