Provider Demographics
NPI:1417043316
Name:AHMEDO, M.BASHAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:M.BASHAR
Middle Name:
Last Name:AHMEDO
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 1:1247 TIMBERSHORE LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1020
Mailing Address - Country:US
Mailing Address - Phone:651-769-4625
Mailing Address - Fax:
Practice Address - Street 1:1247 TIMBERSHORE LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1020
Practice Address - Country:US
Practice Address - Phone:651-769-4625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12287122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist