MEDICARE: MEDEA MOHSENI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	39630	TX

General Provider Information

NPI Number	:	1699451633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEDEA MOHSENI

Provider Business Mailing Address
First Line	:	22 FLEET ST NW APT H22
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-3821
Country	:	US
Telephone Number	:	408-368-5747
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 E ELLIOTT ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-3708
Country	:	US
Telephone Number	:	940-696-9701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	06/26/2023

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Directions to “ MEDEA MOHSENI ” Practice Location

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