=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043985146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILSHAHUOME DENTAL SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 08/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 COMMONWEALTH AVE
-----------------------------------------------------
City | ATTLEBORO FALLS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02763-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-699-0449
-----------------------------------------------------
Fax | 508-699-4344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 COMMONWEALTH AVE
-----------------------------------------------------
City | ATTLEBORO FALLS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02763-1015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-699-0449
-----------------------------------------------------
Fax | 508-699-4344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOHAMED ILSHAHUOME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-371-3561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------