Provider Demographics
NPI:1023122637
Name:MUKDISSI, ZAKI MICHAEL (DMD)
Entity type:Individual
Prefix:MR
First Name:ZAKI
Middle Name:MICHAEL
Last Name:MUKDISSI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WASHINGTON ST
Mailing Address - Street 2:SUITE 472
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-4006
Mailing Address - Country:US
Mailing Address - Phone:781-828-2600
Mailing Address - Fax:781-828-2619
Practice Address - Street 1:95 WASHINGTON ST
Practice Address - Street 2:SUITE 472
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4006
Practice Address - Country:US
Practice Address - Phone:781-828-2600
Practice Address - Fax:781-828-2619
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0201456OtherMASSHEALTH