Provider Demographics
NPI:1144701020
Name:41 STATE RD, LLC
Entity type:Organization
Organization Name:41 STATE RD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-993-9105
Mailing Address - Street 1:1379 TUCKER ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-993-9105
Mailing Address - Fax:508-993-9115
Practice Address - Street 1:1379 TUCKER ROAD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747
Practice Address - Country:US
Practice Address - Phone:508-993-9105
Practice Address - Fax:508-993-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-28
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty