Healthcare Provider Details

I. General information

NPI: 1093352585
Provider Name (Legal Business Name): SIMPLY ORTHODONTICS AND PEDIATRICS CLINTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH ST
CLINTON MA
01510-2556
US

IV. Provider business mailing address

87 ELM ST
HOPKINTON MA
01748-1638
US

V. Phone/Fax

Practice location:
  • Phone: 508-589-8262
  • Fax:
Mailing address:
  • Phone: 508-589-8262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HOUSSAM ALKHOURY
Title or Position: OWNER
Credential: DMD
Phone: 508-505-5040