Provider Demographics
NPI:1962675678
Name:ROBERT G. RAFFERTY, DMD, PC
Entity Type:Organization
Organization Name:ROBERT G. RAFFERTY, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-534-5144
Mailing Address - Street 1:41 DALE ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1249
Mailing Address - Country:US
Mailing Address - Phone:413-534-5144
Mailing Address - Fax:413-538-5508
Practice Address - Street 1:41 DALE ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1249
Practice Address - Country:US
Practice Address - Phone:413-534-5144
Practice Address - Fax:413-538-5508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9550261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0230529Medicaid