Provider Demographics
NPI:1245391416
Name:HERTZ, PETER H (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:H
Last Name:HERTZ
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 G.A.R. HIGHWAY
Mailing Address - Street 2:SUITE #6
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-4566
Mailing Address - Country:US
Mailing Address - Phone:508-676-3041
Mailing Address - Fax:
Practice Address - Street 1:1010 GAR HWY
Practice Address - Street 2:SUITE #6
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4566
Practice Address - Country:US
Practice Address - Phone:508-676-3041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035886204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H12403Medicare UPIN