Provider Demographics
NPI:1912173196
Name:ULLAH, RAHMAN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:RAHMAN
Middle Name:
Last Name:ULLAH
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2225
Mailing Address - Country:US
Mailing Address - Phone:617-462-0116
Mailing Address - Fax:
Practice Address - Street 1:PARK AVE DENTAL CENTER
Practice Address - Street 2:456 PARK AVENUE
Practice Address - City:WORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01610
Practice Address - Country:US
Practice Address - Phone:508-799-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22086122300000X
NYP584011223G0001X
MADN220861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice