Provider Demographics
NPI:1710429170
Name:MOHAREB, MAGED (DENTURIST)
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:
Last Name:MOHAREB
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 SE 17TH CIR APT 230
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-6222
Mailing Address - Country:US
Mailing Address - Phone:310-663-3678
Mailing Address - Fax:
Practice Address - Street 1:10800 SE 17TH CIR APT 230
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-6222
Practice Address - Country:US
Practice Address - Phone:310-663-3678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60669859122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA814366199OtherEIN