Provider Demographics
NPI:1568015568
Name:MAHDI, MOHAMMED AHMED SR
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:AHMED
Last Name:MAHDI
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S BLOOMINGDALE RD STE 9
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1216
Mailing Address - Country:US
Mailing Address - Phone:203-969-4248
Mailing Address - Fax:
Practice Address - Street 1:125 S BLOOMINGDALE RD STE 9
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1216
Practice Address - Country:US
Practice Address - Phone:630-924-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190324351223X0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty