Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DL12141 | MA |
NPI | 1043635311 |
---|---|
Provider Name | Waddah M Alkhouly |
First Address | Malden, MA 02148-4711 |
Second Address | Boston, MA 02118-2308 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/02/2014 |
Last Update Date | 24/02/2014 |