Healthcare Provider Details

I. General information

NPI: 1508190034
Provider Name (Legal Business Name): OSAMA AHMED QUTUB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST
BOSTON MA
02118-2308
US

IV. Provider business mailing address

95 W SQUANTUM ST APT 1215 APT #1215
QUINCY MA
02171-2136
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-5429
  • Fax:
Mailing address:
  • Phone: 202-459-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDL10779
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: