Provider Demographics
NPI:1013975952
Name:GILARDETTI, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:GILARDETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 KINGSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3015
Mailing Address - Country:US
Mailing Address - Phone:401-789-9758
Mailing Address - Fax:
Practice Address - Street 1:691 KINGSTOWN RD
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3015
Practice Address - Country:US
Practice Address - Phone:401-789-9758
Practice Address - Fax:401-789-9763
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152305204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7057362OtherMEDICARE ID
RIU70534Medicare UPIN