Healthcare Provider Details

I. General information

NPI: 1629324652
Provider Name (Legal Business Name): MOHAMED AL-JANABI D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 SPRING ST APT 18
WEST ROXBURY MA
02132
US

IV. Provider business mailing address

250 SPRING ST
WEST ROXBURY MA
02132-5000
US

V. Phone/Fax

Practice location:
  • Phone: 781-999-4109
  • Fax:
Mailing address:
  • Phone: 781-999-4109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDL11624
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: