Healthcare Provider Details

I. General information

NPI: 1356773642
Provider Name (Legal Business Name): DR. ALI ANWAR ABOALELA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS STREET BRIGHAM AND WOMENS HOSPITAL
BOSTON MA
02115
US

IV. Provider business mailing address

151 TREMONT ST APT 17B
BOSTON MA
02111-1125
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-6974
  • Fax:
Mailing address:
  • Phone: 617-515-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDL11825
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: