Provider Demographics
NPI:1750912663
Name:MUJTABA, RABIA
Entity type:Individual
Prefix:
First Name:RABIA
Middle Name:
Last Name:MUJTABA
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 1:1795 MAIN ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1015
Mailing Address - Country:US
Mailing Address - Phone:413-507-0115
Mailing Address - Fax:
Practice Address - Street 1:1795 MAIN ST STE 212
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1015
Practice Address - Country:US
Practice Address - Phone:413-507-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18590671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice