Provider Demographics
NPI:1952715591
Name:ZAKKOOM, MUSTAFA
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:ZAKKOOM
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 1:232 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1315
Mailing Address - Country:US
Mailing Address - Phone:248-824-4916
Mailing Address - Fax:
Practice Address - Street 1:1096 REVERE BEACH PKWY
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-1454
Practice Address - Country:US
Practice Address - Phone:248-824-4916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021277122300000X
MADN18568721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist