Healthcare Provider Details

I. General information

NPI: 1457577884
Provider Name (Legal Business Name): RUSTAM K. DE VITRE, DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 COMMONWEALTH AVE
BOSTON MA
02215
US

IV. Provider business mailing address

392 COMMONWEALTH AVE
BOSTON MA
02215
US

V. Phone/Fax

Practice location:
  • Phone: 617-236-5969
  • Fax: 617-424-6298
Mailing address:
  • Phone: 617-236-5969
  • Fax: 617-424-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number20322
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number18265
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number13701
License Number StateMA

VIII. Authorized Official

Name: DR. RUSTAM K DE VITRE
Title or Position: OWNER
Credential: D.M.D.
Phone: 617-236-5969