| Name: | Boustani Periodontics PC |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Activ |
| Date of Organization in Rhode Island: | 05 Aug 2024 (6 months ago) |
| Identification Number: | 001777372 |
| Purpose: | DENTISTRY |
| Fictitious names: |
Providence Periodontics (trading name, 2024-10-28 - ) |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114745155 | 2024-09-30 | 2024-09-30 | 40 ELMGROVE AVE, PROVIDENCE, RI, 029064104, US | 40 ELMGROVE AVE, PROVIDENCE, RI, 029064104, US | |||||||||||||||
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| Phone | +1 401-421-1717 |
| Fax | 4014210066 |
Authorized person
| Name | DR. GABRIEL BOUSTANI |
| Role | PRESIDENT |
| Phone | 6176404637 |
Taxonomy
| Taxonomy Code | 1223P0300X - Periodontist |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| GABRIEL BOUSTANI | Agent | 40 ELMGROVE AVENUE, PROVIDENCE, RI, 02906, USA |
| Name | Role | Address |
|---|---|---|
| GABRIEL BOUSTANI | INCORPORATOR | 140 GREENWOOD ST NEWTON, MA 02459 USA |
| Number | Name | File Date |
|---|---|---|
| 202460833370 | Fictitious Business Name Statement | 2024-10-28 |
| 202458581050 | Articles of Incorporation | 2024-08-05 |
Date of last update: 29 Oct 2024
Sources: Rhode Island Department of State
