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General NPI Number Information
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NPI Number | 1306235064
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Entity Type | Organization
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Legal Business Name | GABRIEL BOUSTANI DMD PC
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Dates
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Enumeration Date | 01/20/2015
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Last Update Date | 01/23/2015
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Provider Practice Location Address
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Address Line | 1540 BEACON ST
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City | BROOKLINE
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State | MA
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Zip | 02446-2215
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Country | US
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Telephone | 617-738-1950
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Fax |
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Provider Business Mailing Address
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Address Line | 140 GREENWOOD ST
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City | NEWTON
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State | MA
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Zip | 02459-3013
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GABRIEL BOUSTANI
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Credential | DMD, MSD
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Telephone | 617-640-4637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 21631
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License Number State | MA
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