=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518568070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSTAFA ABOULKHAIR, DMD, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3284 RIVERSIDE DR
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-791-2192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3284 RIVERSIDE DR
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-791-2192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOSTAFA ABOULKHAIR
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 434-791-2192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------