Healthcare Provider Details

I. General information

NPI: 1508229402
Provider Name (Legal Business Name): MOHAMED BAYOUMY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EXECUTIVE PARK DR
ALBANY NY
12203-3700
US

IV. Provider business mailing address

2 EXECUTIVE PARK DR
ALBANY NY
12203-3700
US

V. Phone/Fax

Practice location:
  • Phone: 518-446-1001
  • Fax: 518-446-0802
Mailing address:
  • Phone: 518-446-1001
  • Fax: 518-446-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberAH1918018-7009
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number061102
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: