Provider Demographics
NPI:1942751953
Name:MELROSE FAMILY DENTAL PC
Entity Type:Organization
Organization Name:MELROSE FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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, FACP
Authorized Official - Phone:617-669-9839
Mailing Address - Street 1:12 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2810
Mailing Address - Country:US
Mailing Address - Phone:781-665-1552
Mailing Address - Fax:
Practice Address - Street 1:12 PORTER ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2810
Practice Address - Country:US
Practice Address - Phone:781-665-1552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855140122300000X
MADN13354122300000X
MADN221621223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty