Healthcare Provider Details

I. General information

NPI: 1609429018
Provider Name (Legal Business Name): MOHIUDDIN IFAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10448 NORTHCLIFFE BLVD
SPRING HILL FL
34608-3609
US

IV. Provider business mailing address

10448 NORTHCLIFFE BLVD
SPRING HILL FL
34608-3609
US

V. Phone/Fax

Practice location:
  • Phone: 954-903-8587
  • Fax:
Mailing address:
  • Phone: 954-903-8587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24112
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11610
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: