Provider Demographics
NPI:1740027952
Name:EDRISS, ALLA TALAL (DDS)
Entity type:Individual
Prefix:
First Name:ALLA
Middle Name:TALAL
Last Name:EDRISS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 KITTREDGE ST APT 11
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3509
Mailing Address - Country:US
Mailing Address - Phone:857-526-4493
Mailing Address - Fax:
Practice Address - Street 1:4172 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-1730
Practice Address - Country:US
Practice Address - Phone:617-313-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN100003271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice