Provider Demographics
NPI:1952847774
Name:NEW IMAGE DENTISTRY OF PALM BAY ROAD, INC
Entity Type:Organization
Organization Name:NEW IMAGE DENTISTRY OF PALM BAY ROAD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:MUJEEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-536-0157
Mailing Address - Street 1:1764 PALM BAY RD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2904
Mailing Address - Country:US
Mailing Address - Phone:321-725-5512
Mailing Address - Fax:321-725-5592
Practice Address - Street 1:1764 PALM BAY RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2904
Practice Address - Country:US
Practice Address - Phone:321-725-5512
Practice Address - Fax:321-725-5592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty