Provider Demographics
NPI:1124394069
Name:KHOSOUSI, MOHAMMAD (DDS)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:KHOSOUSI
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 1:2285 E FLAMINGO RD
Mailing Address - Street 2:101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5100
Mailing Address - Country:US
Mailing Address - Phone:702-522-9192
Mailing Address - Fax:702-546-5679
Practice Address - Street 1:2285 E FLAMINGO RD
Practice Address - Street 2:101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5100
Practice Address - Country:US
Practice Address - Phone:702-522-9192
Practice Address - Fax:702-546-5679
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4310122300000X
TX297041223G0001X
NV6598122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice