Provider Demographics
NPI:1730470659
Name:NOVISON, ERIC JORDAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JORDAN
Last Name:NOVISON
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 1:28 EXETER ST
Mailing Address - Street 2:APT. 204
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2841
Mailing Address - Country:US
Mailing Address - Phone:732-239-7627
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:DEPT OF ENDODONTICS
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855640122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist