=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053489682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIBLY D MALOUF JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 366 BROADWAY SUITE 100
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-628-8000
-----------------------------------------------------
Fax | 617-628-2370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 366 BROADWAY SUITE 100
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-628-8000
-----------------------------------------------------
Fax | 617-628-2370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 9637
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------