Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 9637 | MA |
NPI | 1053489682 |
---|---|
Provider Name | Dr. Shibly D Malouf JR. |
First Address | Somerville, MA 02145-2812 |
Second Address | Somerville, MA 02145-2812 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
009637 | TUFTS (01) | |
0223573 | (05) | MA |
T56499 | (02) | |
Y03044 | BS (01) | MA |