Provider Demographics
NPI:1801219159
Name:MUJEEB DDS,PA
Entity Type:Organization
Organization Name:MUJEEB DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALCHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-255-1991
Mailing Address - Street 1:3226 LAKE WASHINGTON RD
Mailing Address - Street 2:# 16
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7620
Mailing Address - Country:US
Mailing Address - Phone:321-255-1991
Mailing Address - Fax:321-752-0011
Practice Address - Street 1:3226 LAKE WASHINGTON RD
Practice Address - Street 2:# 16
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7620
Practice Address - Country:US
Practice Address - Phone:321-255-1991
Practice Address - Fax:321-752-0011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW IMAGE DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13401305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service