Healthcare Provider Details

I. General information

NPI: 1023288347
Provider Name (Legal Business Name): LAITH AZZOUNI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 SOUTHBRIDGE ST
AUBURN MA
01501
US

IV. Provider business mailing address

390 SOUTHBRIDGE ST
AUBURN MA
01501-2456
US

V. Phone/Fax

Practice location:
  • Phone: 508-832-0919
  • Fax: 508-832-0426
Mailing address:
  • Phone: 508-832-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN18560
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855086
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: