Provider Demographics
NPI:1609987312
Name:ROSENBERG, MORTON BRUCE (DMD)
Entity Type:Individual
Prefix:
First Name:MORTON
Middle Name:BRUCE
Last Name:ROSENBERG
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 CHANNEL CENTER STREET
Mailing Address - Street 2:#802
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210
Mailing Address - Country:US
Mailing Address - Phone:617-512-7941
Mailing Address - Fax:
Practice Address - Street 1:25 CHANNEL CENTER STREET
Practice Address - Street 2:#802
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210
Practice Address - Country:US
Practice Address - Phone:617-512-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA131941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0249068Medicaid
MA0249068Medicaid
MAT86261Medicare UPIN