Provider Demographics
NPI:1952385742
Name:FIDROCKI, EDWARD HENRY (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HENRY
Last Name:FIDROCKI
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 1:1 KNEELAND ST
Mailing Address - Street 2:ROOM 322 A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:1 KNEELAND ST
Practice Address - Street 2:ROOM 322 A
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-643-8070
Practice Address - Fax:617-643-8122
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist