Provider Demographics
NPI:1710218425
Name:ALAA ALWAZZAN DMD PC
Entity Type:Organization
Organization Name:ALAA ALWAZZAN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAAEDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALWAZZAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSC, FACP
Authorized Official - Phone:617-328-5060
Mailing Address - Street 1:580 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-1909
Mailing Address - Country:US
Mailing Address - Phone:617-328-5060
Mailing Address - Fax:
Practice Address - Street 1:580 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-1909
Practice Address - Country:US
Practice Address - Phone:617-328-5060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223E0200X, 1223G0001X, 1223P0300X, 124Q00000X, 126800000X
MA221621223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty