Provider Demographics
NPI:1477610269
Name:DE VITRE, RUSTAM K (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSTAM
Middle Name:K
Last Name:DE VITRE
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 1:392 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2801
Mailing Address - Country:US
Mailing Address - Phone:617-236-5969
Mailing Address - Fax:617-424-6265
Practice Address - Street 1:392 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2801
Practice Address - Country:US
Practice Address - Phone:617-236-5969
Practice Address - Fax:617-424-6265
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA137011223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics