Provider Demographics
NPI:1689749574
Name:ABDENNOUR, MARIO E (DMD MMSC)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:E
Last Name:ABDENNOUR
Suffix:
Gender:M
Credentials:DMD MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 THISTLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-4745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:978-505-1969
Practice Address - Fax:978-688-6465
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA192421223E0200X
NH32441223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11812OtherBLUE CROSS & BLUE SHIELD