Provider Demographics
NPI:1265495709
Name:ESBAH-TABATABAIE, HAMID R (DMD)
Entity type:Individual
Prefix:
First Name:HAMID
Middle Name:R
Last Name:ESBAH-TABATABAIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:HAMID
Other - Middle Name:R
Other - Last Name:ESBAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:88 MONTVALE AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3643
Mailing Address - Country:US
Mailing Address - Phone:781-438-7206
Mailing Address - Fax:781-279-9029
Practice Address - Street 1:88 MONTVALE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3643
Practice Address - Country:US
Practice Address - Phone:781-438-7206
Practice Address - Fax:781-279-9029
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA190541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0281395Medicaid
MAX20027Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#
MAU70926Medicare UPIN