Provider Demographics
NPI:1497575005
Name:MUSTAFA, HASSAN ABDALLA
Entity type:Individual
Prefix:
First Name:HASSAN
Middle Name:ABDALLA
Last Name:MUSTAFA
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 1:4224 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3456
Mailing Address - Country:US
Mailing Address - Phone:754-308-9573
Mailing Address - Fax:
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4042
Practice Address - Country:US
Practice Address - Phone:508-894-3681
Practice Address - Fax:508-559-5073
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL100216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist