Healthcare Provider Details

I. General information

NPI: 1700976115
Provider Name (Legal Business Name): ROBERT RUSSELL WHITE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE HARVARD SCHOOL OF DENTAL MEDICINE
BOSTON MA
02115
US

IV. Provider business mailing address

188 LONGWOOD AVE HARVARD SCHOOL OF DENTAL MEDICINE
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1445
  • Fax: 617-432-0901
Mailing address:
  • Phone: 617-432-1445
  • Fax: 617-432-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12762
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: