Provider Demographics
NPI:1376243683
Name:KHOURY, NICHOLAS ANDRE
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANDRE
Last Name:KHOURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 MISHAWUM RD UNIT 5041
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2280
Mailing Address - Country:US
Mailing Address - Phone:603-475-0111
Mailing Address - Fax:
Practice Address - Street 1:968 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3989
Practice Address - Country:US
Practice Address - Phone:781-549-8390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1376243683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty