Provider Demographics
NPI:1750394961
Name:NERSASIAN, ROBERT R (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:NERSASIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HIGHLAND AVE
Mailing Address - Street 2:NORTH SHORE HEALTH SYSTEMS
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-354-4173
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-745-8774
Practice Address - Fax:978-741-7534
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0244104Medicaid
MANEX03887OtherBCBS
MANEX03887OtherBCBS