Healthcare Provider Details

I. General information

NPI: 1801279740
Provider Name (Legal Business Name): ABDULLAH OTHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 MAIN ST
WALTHAM MA
02451-7414
US

IV. Provider business mailing address

879 MAIN ST
WALTHAM MA
02451-7414
US

V. Phone/Fax

Practice location:
  • Phone: 781-850-2361
  • Fax:
Mailing address:
  • Phone: 781-850-2361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN1858871
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: