Provider Demographics
NPI:1457825697
Name:MOHEIELDIN, NIVIN M
Entity Type:Individual
Prefix:
First Name:NIVIN
Middle Name:M
Last Name:MOHEIELDIN
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 1:11090 MOUNTAIN VIEW DR APT 62
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8914
Mailing Address - Country:US
Mailing Address - Phone:669-220-0464
Mailing Address - Fax:
Practice Address - Street 1:902 E HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3027
Practice Address - Country:US
Practice Address - Phone:669-220-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice