Basic Information
| Provider Information | |||||||||
| NPI: | 1538320684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTON UNIVERSITY SCHOOL OF DENTAL MEDCINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 PLEASANT ST | ||||||||
| Address2: | APT # 809 | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021484832 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E NEWTON ST | ||||||||
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| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176384750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | KAYAL | ||||||||
| AuthorizedOfficialFirstName: | RAYYAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PERIODONTOLOGY RESIDANT | ||||||||
| AuthorizedOfficialTelephone: | 6176384750 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 9800 | MA | Y | Hospitals | General Acute Care Hospital |
No ID Information.