Provider Demographics
NPI:1073923017
Name:AMSALEM, AVRAHAM (DDS, MD)
Entity Type:Individual
Prefix:
First Name:AVRAHAM
Middle Name:
Last Name:AMSALEM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7881 SAN MARCOS PL
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4125
Mailing Address - Country:US
Mailing Address - Phone:561-685-0909
Mailing Address - Fax:
Practice Address - Street 1:5130 LINTON BLVD STE E3
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6595
Practice Address - Country:US
Practice Address - Phone:561-685-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN216951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program