1326207796 NPI number — M MOHEBAN DMD PC

Table of content: (NPI 1326207796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326207796 NPI number — M MOHEBAN DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M MOHEBAN DMD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326207796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01532-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-393-2522
Provider Business Mailing Address Fax Number:
508-393-9782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01532-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-393-2522
Provider Business Practice Location Address Fax Number:
508-393-9782
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOHEBAN
Authorized Official First Name:
MANSOUR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-393-2522

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  11905 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: X12350 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: X12351 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: X12515 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1331231 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 262609 . This is a "MASS HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 38400 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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