Provider Demographics
NPI:1609429018
Name:IFAZ, MOHIUDDIN
Entity Type:Individual
Prefix:
First Name:MOHIUDDIN
Middle Name:
Last Name:IFAZ
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 1:10448 NORTHCLIFFE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-3609
Mailing Address - Country:US
Mailing Address - Phone:954-903-8587
Mailing Address - Fax:
Practice Address - Street 1:10448 NORTHCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-3609
Practice Address - Country:US
Practice Address - Phone:954-903-8587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24112122300000X
NC11610122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist