Provider Demographics
NPI:1841854510
Name:MOSTAFAVI, MOHAMMAD ALI (DDS)
Entity type:Individual
Prefix:
First Name:MOHAMMAD ALI
Middle Name:
Last Name:MOSTAFAVI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 RIDGE MEADE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8387
Mailing Address - Country:US
Mailing Address - Phone:469-502-1722
Mailing Address - Fax:
Practice Address - Street 1:436 RIDGE MEADE DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8387
Practice Address - Country:US
Practice Address - Phone:469-502-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-27
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346171223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics