Healthcare Provider Details

I. General information

NPI: 1932982782
Provider Name (Legal Business Name): BADR HEFNAWI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 WASHINGTON ST
ROXBURY MA
02119-1227
US

IV. Provider business mailing address

701 MASSACHUSETTS AVE APT 2
BOSTON MA
02118-4060
US

V. Phone/Fax

Practice location:
  • Phone: 312-274-4550
  • Fax:
Mailing address:
  • Phone: 716-615-9929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1860006
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: