Provider Demographics
NPI:1376822064
Name:NKUTUKIRUNDA, MOHAMMED (DDS)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:NKUTUKIRUNDA
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 1:1905 CONVENIENCE PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-8926
Mailing Address - Country:US
Mailing Address - Phone:217-356-7400
Mailing Address - Fax:217-356-7405
Practice Address - Street 1:1905 CONVENIENCE PL
Practice Address - Street 2:SUITE B
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-8926
Practice Address - Country:US
Practice Address - Phone:217-356-7400
Practice Address - Fax:217-356-7405
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028830122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist