Provider Demographics
NPI:1104239318
Name:DENNISON, ROBERTA
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:DENNISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CANAL ST
Mailing Address - Street 2:STE 210
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6701
Mailing Address - Country:US
Mailing Address - Phone:781-338-0500
Mailing Address - Fax:781-338-0000
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA270222207Q00000X
MA260184390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program