Healthcare Provider Details

I. General information

NPI: 1306629290
Provider Name (Legal Business Name): MUSTAFA AL AZZAWI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 DANIEL WEBSTER HWY
NASHUA NH
03060-5536
US

IV. Provider business mailing address

70 EASTERN AVE
MALDEN MA
02148-5014
US

V. Phone/Fax

Practice location:
  • Phone: 603-769-8448
  • Fax:
Mailing address:
  • Phone: 781-338-0818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number25736
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number05206
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDL100711
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN5378
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: