Provider Demographics
NPI:1649761065
Name:ABDUL AZIM, MOHAMAD HASSAN
Entity Type:Individual
Prefix:
First Name:MOHAMAD HASSAN
Middle Name:
Last Name:ABDUL AZIM
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 1:11 FRANCISCAN PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4867
Mailing Address - Country:US
Mailing Address - Phone:909-636-1584
Mailing Address - Fax:
Practice Address - Street 1:2900 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48505-4452
Practice Address - Country:US
Practice Address - Phone:909-636-1584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29520007411223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty