Provider Demographics
NPI:1841831096
Name:ALBURQUERQUE, JIMMY SAMUEL (DMD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:SAMUEL
Last Name:ALBURQUERQUE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WORCESTER ST APT 203
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-3376
Mailing Address - Country:US
Mailing Address - Phone:407-724-2020
Mailing Address - Fax:
Practice Address - Street 1:459 BROADWAY STE 1
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3614
Practice Address - Country:US
Practice Address - Phone:617-389-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist