Provider Demographics
NPI:1053585869
Name:SOUTHBOROUGH DENTAL PARTNERS PLLC
Entity type:Organization
Organization Name:SOUTHBOROUGH DENTAL PARTNERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST (OWNER)
Authorized Official - Prefix:
Authorized Official - First Name:HUSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-KHATEEB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-571-4992
Mailing Address - Street 1:21 TURNPIKE RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-2117
Mailing Address - Country:US
Mailing Address - Phone:508-357-8800
Mailing Address - Fax:508-624-0191
Practice Address - Street 1:21 TURNPIKE RD
Practice Address - Street 2:SUITE F
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-2117
Practice Address - Country:US
Practice Address - Phone:508-357-8800
Practice Address - Fax:508-624-0191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18504261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental