Provider Demographics
NPI:1104238641
Name:FAHEY, ROSS HARRISON (DDS)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:HARRISON
Last Name:FAHEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KNEELAND STREET
Mailing Address - Street 2:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE - OMS DEPT.
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-636-6516
Mailing Address - Fax:
Practice Address - Street 1:1 KNEELAND STREET
Practice Address - Street 2:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE - OMS DEPT.
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-6516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18565401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery