Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DN1856540 | MA |
NPI | 1104238641 |
---|---|
Provider Name | Ross Harrison Fahey |
First Address | Boston, MA 02111 |
Second Address | Boston, MA 02111 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2014 |
Last Update Date | 03/08/2014 |