Healthcare Provider Details

I. General information

NPI: 1689749574
Provider Name (Legal Business Name): MARIO E ABDENNOUR DMD MMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE
BOSTON MA
02115
US

IV. Provider business mailing address

75 THISTLE RD
NORTH ANDOVER MA
01845-4745
US

V. Phone/Fax

Practice location:
  • Phone: 978-505-1969
  • Fax: 978-688-6465
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number19242
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3244
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: