Provider Demographics
NPI:1508190034
Name:QUTUB, OSAMA AHMED
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:AHMED
Last Name:QUTUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 W SQUANTUM ST APT 1215
Mailing Address - Street 2:APT #1215
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2136
Mailing Address - Country:US
Mailing Address - Phone:202-459-8381
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-5429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL107791223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1223P0700XOtherDENTIST