Healthcare Provider Details

I. General information

NPI: 1740611516
Provider Name (Legal Business Name): EHAB JABAH BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 TACOMA ST
WORCESTER MA
01605-3516
US

IV. Provider business mailing address

19 TACOMA ST
WORCESTER MA
01605-3516
US

V. Phone/Fax

Practice location:
  • Phone: 508-595-1115
  • Fax: 508-595-1159
Mailing address:
  • Phone: 508-595-1115
  • Fax: 508-595-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL12093
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: