Healthcare Provider Details

I. General information

NPI: 1629914742
Provider Name (Legal Business Name): DR. MOHAMED ELRASD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S CHEROKEE LN
LODI CA
95240-4266
US

IV. Provider business mailing address

9009 PASO ROBLES WAY
ELK GROVE CA
95758-6132
US

V. Phone/Fax

Practice location:
  • Phone: 209-366-7970
  • Fax:
Mailing address:
  • Phone: 267-351-7657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: