Healthcare Provider Details

I. General information

NPI: 1154947646
Provider Name (Legal Business Name): MOHAMED SAMY MOUSTAFA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 10/09/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W JOE HARVEY BLVD STE B
HOBBS NM
88240-0821
US

IV. Provider business mailing address

2050 E ALGONQUIN RD STE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 575-738-0335
  • Fax:
Mailing address:
  • Phone: 888-988-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24964
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5353
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: