Provider Demographics
NPI:1154811404
Name:ALI, MOHAMED MUKHTAR (DDS)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:MUKHTAR
Last Name:ALI
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 1:8680 MARIGOLD CIR APT 307
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7641
Mailing Address - Country:US
Mailing Address - Phone:240-765-4938
Mailing Address - Fax:
Practice Address - Street 1:4700 CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:240-765-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND139771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice