Provider Demographics
NPI:1265459994
Name:ELMASOURI, SABAH AHMEIDA (BDS DMD)
Entity Type:Individual
Prefix:
First Name:SABAH
Middle Name:AHMEIDA
Last Name:ELMASOURI
Suffix:
Gender:F
Credentials:BDS DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MEXICO ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316
Mailing Address - Country:US
Mailing Address - Phone:315-245-4037
Mailing Address - Fax:315-245-4037
Practice Address - Street 1:24 MEXICO ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316
Practice Address - Country:US
Practice Address - Phone:315-245-4037
Practice Address - Fax:315-245-4037
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0437831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01351651Medicaid