Healthcare Provider Details

I. General information

NPI: 1063335792
Provider Name (Legal Business Name): MOHAMAD ELGHOUL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4841 MONROE ST STE 260
TOLEDO OH
43623-5324
US

IV. Provider business mailing address

7640 MAPLE ST
DEARBORN MI
48126-1135
US

V. Phone/Fax

Practice location:
  • Phone: 419-475-6554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901603196
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.028611
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: