Provider Demographics
NPI:1518538354
Name:AL-ROOMI, MODAR
Entity Type:Individual
Prefix:
First Name:MODAR
Middle Name:
Last Name:AL-ROOMI
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 1:69 PARK DR APT 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5208
Mailing Address - Country:US
Mailing Address - Phone:424-355-3864
Mailing Address - Fax:
Practice Address - Street 1:1030 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7448
Practice Address - Country:US
Practice Address - Phone:781-697-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18590281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice