Provider Demographics
NPI:1356479786
Name:SELEEM, MOHAMED MOSTAFA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:MOSTAFA
Last Name:SELEEM
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 1:11458 SOUTHAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-268-4616
Mailing Address - Fax:909-355-2715
Practice Address - Street 1:15366 SEVENTH ST STE G
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3837
Practice Address - Country:US
Practice Address - Phone:760-245-8616
Practice Address - Fax:760-245-2490
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice