Healthcare Provider Details

I. General information

NPI: 1306235064
Provider Name (Legal Business Name): GABRIEL BOUSTANI DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 BEACON ST
BROOKLINE MA
02446-2215
US

IV. Provider business mailing address

140 GREENWOOD ST
NEWTON MA
02459-3013
US

V. Phone/Fax

Practice location:
  • Phone: 617-738-1950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number21631
License Number StateMA

VIII. Authorized Official

Name: DR. GABRIEL BOUSTANI
Title or Position: PRESIDENT
Credential: DMD, MSD
Phone: 617-640-4637