Provider Demographics
NPI:1578285151
Name:WAHEED, MISHALL
Entity Type:Individual
Prefix:
First Name:MISHALL
Middle Name:
Last Name:WAHEED
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 1:2235 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2235 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3800
Practice Address - Country:US
Practice Address - Phone:321-956-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist