Provider Demographics
NPI:1568163012
Name:CITIDENTAL CENTER BROOKLINE
Entity Type:Organization
Organization Name:CITIDENTAL CENTER BROOKLINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EYAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SALLOUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-874-1511
Mailing Address - Street 1:637 WASHINGTON ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 WASHINGTON ST STE 210
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4579
Practice Address - Country:US
Practice Address - Phone:617-874-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental