Provider Demographics
NPI:1932580719
Name:MAHMOOD, ABU BAKER OBAID
Entity Type:Individual
Prefix:
First Name:ABU BAKER
Middle Name:OBAID
Last Name:MAHMOOD
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 1:1049 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103
Mailing Address - Country:US
Mailing Address - Phone:413-739-1100
Mailing Address - Fax:
Practice Address - Street 1:1049 MAIN ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18568641223D0001X
CT0115061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health