Provider Demographics
NPI:1477667079
Name:WELLINGTON CIRCLE DENTAL PC
Entity Type:Organization
Organization Name:WELLINGTON CIRCLE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZAKI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MUKDISSI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-306-9644
Mailing Address - Street 1:616 FELLSWAY
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-306-9644
Mailing Address - Fax:781-306-9726
Practice Address - Street 1:616 FELLSWAY
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-306-9644
Practice Address - Fax:781-306-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194751223G0001X
MA192551223P0300X
MA210631223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty