Healthcare Provider Details

I. General information

NPI: 1174180061
Provider Name (Legal Business Name): MONA HOVAIZI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2019
Last Update Date: 05/09/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4561 MAINE ST
QUINCY IL
62305-5851
US

IV. Provider business mailing address

4561 MAINE ST
QUINCY IL
62305-5851
US

V. Phone/Fax

Practice location:
  • Phone: 217-290-5288
  • Fax:
Mailing address:
  • Phone: 434-242-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1858316
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: