Provider Demographics
NPI:1073250247
Name:MOGHUL, ADIL SHAHBAZ (DDS)
Entity Type:Individual
Prefix:
First Name:ADIL
Middle Name:SHAHBAZ
Last Name:MOGHUL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 GARDENA AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5815
Mailing Address - Country:US
Mailing Address - Phone:612-558-4069
Mailing Address - Fax:
Practice Address - Street 1:319 NE VIVION RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4510
Practice Address - Country:US
Practice Address - Phone:816-459-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220179641223G0001X
MO20220176941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice