Provider Demographics
NPI:1801279740
Name:OTHMAN, ABDULLAH
Entity type:Individual
Prefix:
First Name:ABDULLAH
Middle Name:
Last Name:OTHMAN
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 1:879 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-7414
Mailing Address - Country:US
Mailing Address - Phone:781-850-2361
Mailing Address - Fax:
Practice Address - Street 1:879 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7414
Practice Address - Country:US
Practice Address - Phone:781-850-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18588711223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty