Provider Demographics
NPI:1295469278
Name:MAHMOUD, SELMA GHASSAN
Entity Type:Individual
Prefix:
First Name:SELMA
Middle Name:GHASSAN
Last Name:MAHMOUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 DEERING PL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-4101
Mailing Address - Country:US
Mailing Address - Phone:512-825-7163
Mailing Address - Fax:
Practice Address - Street 1:6500 N MOPAC EXPY STE 2204
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3282
Practice Address - Country:US
Practice Address - Phone:512-489-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist