Provider Demographics
NPI:1508464603
Name:HOUSAMI, THABET
Entity Type:Individual
Prefix:
First Name:THABET
Middle Name:
Last Name:HOUSAMI
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 1:635 ALBANY STREET G-201
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2392
Mailing Address - Country:US
Mailing Address - Phone:617-358-3481
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY STREET G-201
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2392
Practice Address - Country:US
Practice Address - Phone:617-358-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL14598122300000X, 1223E0200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics