Provider Demographics
NPI:1104464684
Name:MOULA, KAZI SHAFIUL (DDS)
Entity type:Individual
Prefix:
First Name:KAZI
Middle Name:SHAFIUL
Last Name:MOULA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E NEES AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-6014
Mailing Address - Country:US
Mailing Address - Phone:267-444-8827
Mailing Address - Fax:
Practice Address - Street 1:WESTERN DENTAL/ BRIDENT 150BFO
Practice Address - Street 2:3077 W SHAW AVE
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711
Practice Address - Country:US
Practice Address - Phone:559-490-1327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist