Provider Demographics
NPI:1437163888
Name:DESAUTELS, ROBERT ALLAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLAN
Last Name:DESAUTELS
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 1:25 BRUUER AVE
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-2210
Mailing Address - Country:US
Mailing Address - Phone:413-596-2592
Mailing Address - Fax:
Practice Address - Street 1:34 MARSDEN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-1615
Practice Address - Country:US
Practice Address - Phone:413-733-8966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0260339OtherMASSHEALTH