=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568293611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. TAREQ ALSARRAF
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2024
-----------------------------------------------------
Last Update Date | 06/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 FRUIT ST WANG 230
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-726-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 FRUIT ST WANG 230
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 0442000526
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DL100767
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------