Provider Demographics
NPI:1730102088
Name:JEZEWSKI, PETER ALAN (DDS PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALAN
Last Name:JEZEWSKI
Suffix:
Gender:M
Credentials:DDS PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 THE FENWAY
Mailing Address - Street 2:THE FORSYTH INSTITUTE ROOM 411
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-892-8491
Mailing Address - Fax:617-892-8303
Practice Address - Street 1:100 EVERETT AVE
Practice Address - Street 2:UNIT 5
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150
Practice Address - Country:US
Practice Address - Phone:617-884-4444
Practice Address - Fax:617-884-4448
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212381223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0204544Medicaid