Provider Demographics
NPI:1245890722
Name:BOU-ABBOUD, MARC (DMD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BOU-ABBOUD
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 1:24 MIDDLESEX CIR APT 3
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-6264
Mailing Address - Country:US
Mailing Address - Phone:304-673-5493
Mailing Address - Fax:
Practice Address - Street 1:40 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LUNENBURG
Practice Address - State:MA
Practice Address - Zip Code:01462-1248
Practice Address - Country:US
Practice Address - Phone:978-401-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18582691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice