Healthcare Provider Details

I. General information

NPI: 1487645008
Provider Name (Legal Business Name): ROBERT BRUCE DONOFF DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PARKMAN ST WAC 230
BOSTON MA
02114-3117
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8222
  • Fax: 617-726-2814
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number37230
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: