Provider Demographics
NPI:1194379792
Name:AHMED, MUSTAFA HUSSEIN
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:HUSSEIN
Last Name:AHMED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8904 W BROAD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5826
Mailing Address - Country:US
Mailing Address - Phone:919-527-4914
Mailing Address - Fax:
Practice Address - Street 1:8904 W BROAD ST STE 202
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-5826
Practice Address - Country:US
Practice Address - Phone:804-716-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist