Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 19460 | MA |
NPI | 1124199500 |
---|---|
Provider Name | Dr. Constant Crohin |
First Address | Watertown, MA 02472-3017 |
Second Address | Waltham, MA 02453-4206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2006 |
Last Update Date | 08/07/2007 |