Provider Demographics
NPI:1255688065
Name:SIRAGE, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:SIRAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NW 136TH AVE # C110
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2624
Mailing Address - Country:US
Mailing Address - Phone:954-846-7171
Mailing Address - Fax:954-846-7170
Practice Address - Street 1:165 NW 136TH AVE # C110
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33325-2624
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:954-846-7170
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN195811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry