Provider Demographics
NPI:1063659571
Name:SHOUKOOHI, MASOUD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:
Last Name:SHOUKOOHI
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 1:99 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2826
Mailing Address - Country:US
Mailing Address - Phone:770-386-3908
Mailing Address - Fax:770-386-9986
Practice Address - Street 1:99 MOCKINGBIRD DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2826
Practice Address - Country:US
Practice Address - Phone:770-386-3908
Practice Address - Fax:770-386-9986
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist