Provider Demographics
NPI:1891288817
Name:REASON, MARISA B (DMD, MSD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:B
Last Name:REASON
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 MASSACHUSETTS AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1110
Mailing Address - Country:US
Mailing Address - Phone:978-697-4968
Mailing Address - Fax:
Practice Address - Street 1:292 CHAUNCY ST # 150
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1203
Practice Address - Country:US
Practice Address - Phone:508-261-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18578911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty