Provider Demographics
NPI:1649766593
Name:TABAA, MOSTAFA (DDS)
Entity Type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:
Last Name:TABAA
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 1:530 BASIL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1004
Mailing Address - Country:US
Mailing Address - Phone:215-939-5062
Mailing Address - Fax:
Practice Address - Street 1:18 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9168
Practice Address - Country:US
Practice Address - Phone:215-939-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10049122300000X
OH300266061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist