Provider Demographics
NPI:1699812180
Name:MOHAMED, MOHAMED H
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:H
Last Name:MOHAMED
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 1:1600 STANDIFORD AVE
Mailing Address - Street 2:#100
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0515
Mailing Address - Country:US
Mailing Address - Phone:209-634-0500
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:703 N GOLDEN STATE BLVD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3953
Practice Address - Country:US
Practice Address - Phone:209-634-0500
Practice Address - Fax:209-634-5038
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47957Medicaid