Healthcare Provider Details

I. General information

NPI: 1407386766
Provider Name (Legal Business Name): HANI MASSOUD HANNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

179 PRESIDENTS LN UNIT 2G
QUINCY MA
02169-1979
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone: 703-479-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number1111111
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: