Provider Demographics
NPI:1417073586
Name:ROONEY, ELIZABETH G (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:G
Last Name:ROONEY
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 1:799 E BROADWAY
Mailing Address - Street 2:APT #3
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2346
Mailing Address - Country:US
Mailing Address - Phone:917-608-8055
Mailing Address - Fax:
Practice Address - Street 1:451 D ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-1950
Practice Address - Country:US
Practice Address - Phone:617-737-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02117559Medicaid