Provider Demographics
NPI:1598754947
Name:IMAM, MOHAMMED MANSOORUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:MANSOORUL
Last Name:IMAM
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 1:5611 94TH ST
Mailing Address - Street 2:SUITE # LN
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5080
Mailing Address - Country:US
Mailing Address - Phone:718-271-4424
Mailing Address - Fax:718-271-4799
Practice Address - Street 1:5611 94TH ST
Practice Address - Street 2:SUITE # LN
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5080
Practice Address - Country:US
Practice Address - Phone:718-271-4424
Practice Address - Fax:718-271-4799
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02241183Medicaid