Provider Demographics
NPI:1316425515
Name:HAIDAR, SHADI KARAM (DMD)
Entity type:Individual
Prefix:DR
First Name:SHADI
Middle Name:KARAM
Last Name:HAIDAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 DESOTO RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-6033
Mailing Address - Country:US
Mailing Address - Phone:617-259-7027
Mailing Address - Fax:
Practice Address - Street 1:95 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4006
Practice Address - Country:US
Practice Address - Phone:781-828-2600
Practice Address - Fax:781-828-2619
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18581271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program