Provider Demographics
NPI:1881685238
Name:FINE, GERALD STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:STEPHEN
Last Name:FINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:781-344-7100
Mailing Address - Fax:617-975-1990
Practice Address - Street 1:1223 BEACON STREET
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5302
Practice Address - Country:US
Practice Address - Phone:617-731-6060
Practice Address - Fax:617-975-1990
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA16001OtherHPHC
MAX04231OtherBS & MEDICARE
MAV03967Medicare ID - Type Unspecified
MA16001OtherHPHC