Healthcare Provider Details

I. General information

NPI: 1285871004
Provider Name (Legal Business Name): NABIL M ALSOURANI B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

3920 MYSTIC VALLEY PKWY APARTMENT # 517
MEDFORD MA
02155-6912
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6531
  • Fax:
Mailing address:
  • Phone: 781-475-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDL10508
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: