Basic Information
| Provider Information | |||||||||
| NPI: | 1245739291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALSENDI | ||||||||
| FirstName: | MARYAM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 BOYLSTON ST APT 14F | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021997813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8573096390 | ||||||||
| FaxNumber: | 6176386170 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E NEWTON ST STE G217 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176384750 | ||||||||
| FaxNumber: | 6176386170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2018 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | DL13458 | MA | Y | Dental Providers | Dentist | Periodontics |
ID Information
| ID | Type | State | Issuer | Description | BB1832268PMA | 05 | MA | MEDICAID |