Provider Demographics
NPI:1780610121
Name:ROOT, EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ROOT
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 1:256 GREAT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1916
Mailing Address - Country:US
Mailing Address - Phone:978-534-9216
Mailing Address - Fax:978-537-6931
Practice Address - Street 1:256 GREAT RD
Practice Address - Street 2:SUITE 5
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1916
Practice Address - Country:US
Practice Address - Phone:978-534-9216
Practice Address - Fax:978-537-6931
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice