Healthcare Provider Details

I. General information

NPI: 1356351696
Provider Name (Legal Business Name): BAHRAM GHASSEMI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 NEW EDGERLY RD
BOSTON MA
02115
US

IV. Provider business mailing address

68 NEW EDGERLY RD
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-262-5880
  • Fax: 617-859-8804
Mailing address:
  • Phone: 617-262-5880
  • Fax: 617-859-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13913
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13913
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: