=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336790609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAHMOUD HOMSI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 SOUTH ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-530-5111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 SOUTH ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-530-5111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN1858485
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 04721
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------