Healthcare Provider Details

I. General information

NPI: 1255441804
Provider Name (Legal Business Name): SADRU P KABANI DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST G-04 BONSTON UNIV OF DENTAL MED, DEPT OF ORAL & MAXILLO PATH
BOSTON MA
02118-2308
US

IV. Provider business mailing address

100 E NEWTON ST G-04 BONSTON UNIV OF DENTAL MED, DEPT OF ORAL & MAXILLO PATH
BOSTON MA
02118-2308
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-5005
  • Fax: 617-638-4697
Mailing address:
  • Phone: 617-638-5005
  • Fax: 617-638-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number14278
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: