Provider Demographics
NPI:1841593852
Name:MOHEB DMD INC
Entity Type:Organization
Organization Name:MOHEB DMD INC
Other - Org Name:SAN MIGUEL DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASILLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-300-3992
Mailing Address - Street 1:1844 SAN MIGUEL DR STE 206
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4963
Mailing Address - Country:US
Mailing Address - Phone:925-457-6906
Mailing Address - Fax:925-952-7376
Practice Address - Street 1:1844 SAN MIGUEL DR
Practice Address - Street 2:STE 206
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4962
Practice Address - Country:US
Practice Address - Phone:925-279-3326
Practice Address - Fax:925-279-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841593852Medicaid