Provider Demographics
NPI:1770152340
Name:ATRA, MOHAMMED
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:ATRA
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 1:1414 10TH PL S APT G
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4686
Mailing Address - Country:US
Mailing Address - Phone:352-382-1454
Mailing Address - Fax:
Practice Address - Street 1:8415 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5028
Practice Address - Country:US
Practice Address - Phone:352-382-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist