Provider Demographics
NPI:1740216084
Name:BOUSTANI, GABRIEL (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:BOUSTANI
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3013
Mailing Address - Country:US
Mailing Address - Phone:617-640-4637
Mailing Address - Fax:
Practice Address - Street 1:1540 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2215
Practice Address - Country:US
Practice Address - Phone:617-738-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics