Provider Demographics
NPI:1265779581
Name:ROSENBERG, FAWN (DMD, FAGD)
Entity type:Individual
Prefix:DR
First Name:FAWN
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 WALTHAM STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421
Mailing Address - Country:US
Mailing Address - Phone:781-861-6008
Mailing Address - Fax:781-240-0264
Practice Address - Street 1:922 WALTHAM STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421
Practice Address - Country:US
Practice Address - Phone:781-861-6008
Practice Address - Fax:781-240-0264
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist