Provider Demographics
NPI:1700319035
Name:MUSTAFA, KAAENAAT
Entity Type:Individual
Prefix:
First Name:KAAENAAT
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BILLINGRATH TURN LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-2908
Mailing Address - Country:US
Mailing Address - Phone:919-802-2148
Mailing Address - Fax:
Practice Address - Street 1:2301 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4427
Practice Address - Country:US
Practice Address - Phone:919-802-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109151223D0001X, 1223G0001X
PADS043566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice