Provider Demographics
NPI:1881117422
Name:MOHAMED, MOSTAFA A
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:A
Last Name:MOHAMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5430
Mailing Address - Country:US
Mailing Address - Phone:917-330-2277
Mailing Address - Fax:
Practice Address - Street 1:735 ATTUCKS LN
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1867
Practice Address - Country:US
Practice Address - Phone:917-330-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL133491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice