Healthcare Provider Details

I. General information

NPI: 1376657478
Provider Name (Legal Business Name): DR. JERROLD NATHAN RAAB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 RTE 23
MONTEREY MA
01245-0522
US

IV. Provider business mailing address

PO BOX 522 RTE 23
MONTEREY MA
01245-0522
US

V. Phone/Fax

Practice location:
  • Phone: 413-528-6520
  • Fax: 413-528-6520
Mailing address:
  • Phone: 413-528-6520
  • Fax: 413-528-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number15788
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: