Healthcare Provider Details

I. General information

NPI: 1255688065
Provider Name (Legal Business Name): MOHAMED SIRAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 NW 136TH AVE # C110
PLANTATION FL
33325-2624
US

IV. Provider business mailing address

165 NW 136TH AVE # C110
PLANTATION FL
33325-2624
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax: 954-846-7170
Mailing address:
  • Phone: 954-846-7171
  • Fax: 954-846-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN19581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: