Provider Demographics
NPI:1184779977
Name:TESONE, PAUL EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:TESONE
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 1:563 BROADWAY
Mailing Address - Street 2:STE 4
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3749
Mailing Address - Country:US
Mailing Address - Phone:617-389-4950
Mailing Address - Fax:617-389-8604
Practice Address - Street 1:563 BROADWAY
Practice Address - Street 2:#4
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:617-389-4950
Practice Address - Fax:617-389-8604
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0280011Medicaid
MAX11108OtherBCBSMA#1
MAX11109OtherBCBSMA#2
MA0230111Medicaid
MA0280011Medicaid
MA0230111Medicaid