Healthcare Provider Details

I. General information

NPI: 1194210849
Provider Name (Legal Business Name): MOHAMED R ILSHAHUOME DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 COMMONWEALTH AVE
ATTLEBORO FALLS MA
02763-1015
US

IV. Provider business mailing address

103 COMMONWEALTH AVE
ATTLEBORO FALLS MA
02763-1015
US

V. Phone/Fax

Practice location:
  • Phone: 508-699-0449
  • Fax: 508-699-4344
Mailing address:
  • Phone: 646-371-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number063595
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL13593
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: