Provider Demographics
NPI:1518351964
Name:BOUKHEIR, MOHAMED ALI (DMD)
Entity Type:Individual
Prefix:
First Name:MOHAMED ALI
Middle Name:
Last Name:BOUKHEIR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:268 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-2269
Practice Address - Country:US
Practice Address - Phone:973-822-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030599122300000X
NJ22DI027780001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist