Healthcare Provider Details

I. General information

NPI: 1043985146
Provider Name (Legal Business Name): ILSHAHUOME DENTAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
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: 508-699-0449
  • Fax: 508-699-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMED ILSHAHUOME
Title or Position: OWNER
Credential:
Phone: 646-371-3561