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21 Custom House St Ste 110 Boston MA 02110-3525 | |
| (617) 840-0627 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist - Periodontics |
| Location | 21 Custom House St Ste 110, Boston, Massachusetts |
| Authorized Official Name and Position | Andre Hashem (OWNER) |
| Authorized Official Contact | 6178400627 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
15 Waverly St Apt 260 Brighton MA 02135-1245 Ph: (617) 840-0627 | 21 Custom House St Ste 110 Boston MA 02110-3525 Ph: (617) 840-0627 |
| NPI Number | 1992294979 |
|---|---|
| Provider Enumeration Date | 05/06/2018 |
| Last Update Date | 05/06/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1992294979 | NPI | - | NPPES |
| 1487727301 | Other | DELTA DENTAL PREMIER | |
| 1487727301 | Other | BLUE CROSS BLUE SHIELD DENTAL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0300X | Dentist - Periodontics | DN1856740 (Massachusetts) | Primary |
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