Provider Demographics
NPI:1154063469
Name:MOHAMED, TARIG A ELMUBARAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARIG A ELMUBARAK
Middle Name:
Last Name:MOHAMED
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:PO BOX 8594
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-0594
Mailing Address - Country:US
Mailing Address - Phone:916-752-1114
Mailing Address - Fax:
Practice Address - Street 1:725 S BIXEL ST APT 662
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2249
Practice Address - Country:US
Practice Address - Phone:916-752-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist