Provider Demographics
NPI:1225757784
Name:ELGHADAFI, RADWA T
Entity Type:Individual
Prefix:DR
First Name:RADWA
Middle Name:T
Last Name:ELGHADAFI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 OVERLOOK RIDGE TER UNIT 110
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1194
Mailing Address - Country:US
Mailing Address - Phone:201-736-5462
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:617-358-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL15335122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist