Provider Demographics
NPI:1609214105
Name:OTHMAN, MOHAMED
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:OTHMAN
Suffix:
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 1:12900 LAKE AVE
Mailing Address - Street 2:APT 2007
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1577
Mailing Address - Country:US
Mailing Address - Phone:734-277-2897
Mailing Address - Fax:
Practice Address - Street 1:2124 CORNELL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-3804
Practice Address - Country:US
Practice Address - Phone:734-277-2897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414004122300000X
OH30.024057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist