Provider Demographics
NPI:1780278655
Name:MUSTAFA, HASAN MOHAMMED
Entity type:Individual
Prefix:
First Name:HASAN
Middle Name:MOHAMMED
Last Name:MUSTAFA
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 1:3655 CASS ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-4531
Mailing Address - Country:US
Mailing Address - Phone:248-346-5442
Mailing Address - Fax:
Practice Address - Street 1:286 EUCLID AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3612
Practice Address - Country:US
Practice Address - Phone:949-800-9524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist