Healthcare Provider Details

I. General information

NPI: 1740216084
Provider Name (Legal Business Name): GABRIEL BOUSTANI D.M.D., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
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: 617-640-4637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: