Healthcare Provider Details

I. General information

NPI: 1154617686
Provider Name (Legal Business Name): CHRISTOPHER ROBERT DESESA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VAN DEENE AVE SUITE 201
WEST SPRINGFIELD MA
01089-3258
US

IV. Provider business mailing address

75 VAN DEENE AVE SUITE 201
WEST SPRINGFIELD MA
01089-3258
US

V. Phone/Fax

Practice location:
  • Phone: 413-788-9621
  • Fax: 413-788-0103
Mailing address:
  • Phone: 413-788-9621
  • Fax: 413-788-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number011521
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1856824
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: