Provider Demographics
NPI:1801530373
Name:AL-BAGHDADI, MOHAMMED KHALIL SHAKER
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:KHALIL SHAKER
Last Name:AL-BAGHDADI
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 1:1950 W TIERRA BUENA LN UNIT 1103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4519
Mailing Address - Country:US
Mailing Address - Phone:520-308-1280
Mailing Address - Fax:
Practice Address - Street 1:230 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3101
Practice Address - Country:US
Practice Address - Phone:602-362-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011751122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program