Healthcare Provider Details

I. General information

NPI: 1750394961
Provider Name (Legal Business Name): ROBERT R NERSASIAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLAND AVE SUITE 201
SALEM MA
01970
US

IV. Provider business mailing address

81 HIGHLAND AVE NORTH SHORE HEALTH SYSTEMS
SALEM MA
01970
US

V. Phone/Fax

Practice location:
  • Phone: 978-745-8774
  • Fax: 978-741-7534
Mailing address:
  • Phone: 978-354-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11039
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: