Provider Demographics
NPI:1386851996
Name:DERROUCHE, ANISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANISSA
Middle Name:
Last Name:DERROUCHE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1113
Mailing Address - Country:US
Mailing Address - Phone:781-729-2479
Mailing Address - Fax:
Practice Address - Street 1:921 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3107
Practice Address - Country:US
Practice Address - Phone:617-492-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20671122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist