=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164045357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMED ATEF YOUSSEF DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2020
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 BOULEVARD ST-LUC, SUITE 201
-----------------------------------------------------
City | SAINT JEAN SUR RICHELIEU
-----------------------------------------------------
State | QUEBEC
-----------------------------------------------------
Zip | J2W 0J3
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 450-349-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 RUE BERLIOZ
-----------------------------------------------------
City | VERDUN
-----------------------------------------------------
State | QC
-----------------------------------------------------
Zip | H3E1M1
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 016.0133936
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------