Provider Demographics
NPI:1932982782
Name:HEFNAWI, BADR
Entity Type:Individual
Prefix:
First Name:BADR
Middle Name:
Last Name:HEFNAWI
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 1:701 MASSACHUSETTS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4060
Mailing Address - Country:US
Mailing Address - Phone:716-615-9929
Mailing Address - Fax:
Practice Address - Street 1:3033 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1227
Practice Address - Country:US
Practice Address - Phone:312-274-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1860006122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program