Provider Demographics
NPI:1114593746
Name:TIRTASHI, MOHAMMAD (DMD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:TIRTASHI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:
Other - Last Name:TIRTASHI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3300 32ND AVE S STE 103
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5803
Mailing Address - Country:US
Mailing Address - Phone:701-765-3494
Mailing Address - Fax:
Practice Address - Street 1:1264 E JOPPA RD STE 100
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5825
Practice Address - Country:US
Practice Address - Phone:410-842-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND24421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice