Provider Demographics
NPI:1730411372
Name:ROSSETTI, ROBERT A (DMD, MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:ROSSETTI
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 PALOMBA DRIVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-253-9298
Mailing Address - Fax:860-253-9689
Practice Address - Street 1:76 PALOMBA DRIVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-253-9298
Practice Address - Fax:860-253-9689
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007472204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU33340Medicare UPIN
CT190000778Medicare PIN