Healthcare Provider Details

I. General information

NPI: 1851580708
Provider Name (Legal Business Name): DR. BASIM JAMAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 HARRISON AVE, FGH BUILDING 4TH FLOOR
BOSTON MA
02118-2905
US

IV. Provider business mailing address

28 9TH ST APT 707
MEDFORD MA
02155-5167
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-7933
  • Fax:
Mailing address:
  • Phone: 267-243-5712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDL11067
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: