Provider Demographics
NPI:1326313776
Name:DAKKAK, MARY ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:DAKKAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W. SQUANTUM ST
Practice Address - Street 2:
Practice Address - City:NORTH QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171
Practice Address - Country:US
Practice Address - Phone:617-376-3000
Practice Address - Fax:617-774-1905
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272706207Q00000X
DCMD044387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110127425AMedicaid