Provider Demographics
NPI:1104233634
Name:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
Entity type:Organization
Organization Name:TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSTRUCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALA
Authorized Official - Middle Name:OMAR
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:BDS, MSC
Authorized Official - Phone:407-421-4607
Mailing Address - Street 1:1 KNEELAND ST # 224
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:407-421-4607
Mailing Address - Fax:
Practice Address - Street 1:ONE KNEELAND ST ROOM 224
Practice Address - Street 2:TUFTS DENTAL SCHOOL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:407-421-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTESS OF TUFTS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF10975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty