=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881736684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOSTAFA GHULAM BARAKZOY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 02/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38056 MARTHA AVE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94536-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-505-9409
-----------------------------------------------------
Fax | 510-505-9764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38056 MARTHA AVENUE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94536-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-505-9409
-----------------------------------------------------
Fax | 510-505-9764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 44291
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------