Provider Demographics
NPI:1619088986
Name:KOUTRACH, MOHAMAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:
Last Name:KOUTRACH
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 1:4116B CHILDRESS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-1012
Mailing Address - Country:US
Mailing Address - Phone:281-855-7800
Mailing Address - Fax:281-379-7341
Practice Address - Street 1:8111 CYPRESSWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SPRIN
Practice Address - State:TX
Practice Address - Zip Code:77379
Practice Address - Country:US
Practice Address - Phone:281-855-7800
Practice Address - Fax:281-379-7341
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017307122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist