Provider Demographics
NPI:1376312496
Name:AL MAMUN, MD (DDS)
Entity Type:Individual
Prefix:
First Name:MD
Middle Name:
Last Name:AL MAMUN
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 1:1680 N THOMPSON DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1329
Mailing Address - Country:US
Mailing Address - Phone:631-355-1485
Mailing Address - Fax:
Practice Address - Street 1:5501 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-5414
Practice Address - Country:US
Practice Address - Phone:916-384-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1097841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice