Healthcare Provider Details

I. General information

NPI: 1477083566
Provider Name (Legal Business Name): LAURA EILEEN RUSHFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE
BOSTON MA
02115-5819
US

IV. Provider business mailing address

114 BARTLETT ST
BOSTON MA
02129-2419
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1857620
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: