Provider Demographics
NPI:1033665435
Name:AL MUDHAFAR, MUDHER
Entity Type:Individual
Prefix:
First Name:MUDHER
Middle Name:
Last Name:AL MUDHAFAR
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 1:8928 E R L THORNTON FWY STE 106
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6173
Mailing Address - Country:US
Mailing Address - Phone:864-593-6105
Mailing Address - Fax:
Practice Address - Street 1:2916 N US HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2546
Practice Address - Country:US
Practice Address - Phone:903-487-0349
Practice Address - Fax:678-285-4757
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-27
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18573981223G0001X
TX328971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice