Provider Demographics
NPI:1881105484
Name:PROFESSIONAL DENTAL IMAGE
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL IMAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAKKOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-824-4916
Mailing Address - Street 1:770 BOYLSTON ST APT 15H
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02199-7713
Mailing Address - Country:US
Mailing Address - Phone:248-824-4916
Mailing Address - Fax:
Practice Address - Street 1:53 BIGELOW AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2009
Practice Address - Country:US
Practice Address - Phone:248-824-4916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856872261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental