Provider Demographics
NPI:1790248235
Name:MOURAD, JAD
Entity Type:Individual
Prefix:
First Name:JAD
Middle Name:
Last Name:MOURAD
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 1:101 MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4530
Mailing Address - Country:US
Mailing Address - Phone:781-395-5545
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4530
Practice Address - Country:US
Practice Address - Phone:781-395-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858810122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist