Provider Demographics
NPI:1124450705
Name:FATIMA, AMBEREEN (DDS)
Entity type:Individual
Prefix:
First Name:AMBEREEN
Middle Name:
Last Name:FATIMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:FNU
Other - Middle Name:AMBEREEN
Other - Last Name:FATIMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:DENTAL DEPT, 3RD FLOOR
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7910
Mailing Address - Fax:508-860-7774
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:DENTAL DEPT, 3RD FLOOR
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7910
Practice Address - Fax:508-860-7774
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564121223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice