Provider Demographics
NPI:1922363126
Name:ALMANDALAWI, MOHAMMED KASSIM (DMD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:KASSIM
Last Name:ALMANDALAWI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1217
Mailing Address - Country:US
Mailing Address - Phone:909-367-0755
Mailing Address - Fax:
Practice Address - Street 1:11921 MISTY COVE CT APT 103
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7149
Practice Address - Country:US
Practice Address - Phone:909-367-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014137041223G0001X
390200000X
IL019.0313421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty