Provider Demographics
NPI:1194210849
Name:ILSHAHUOME, MOHAMED R (DMD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:R
Last Name:ILSHAHUOME
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02763-1015
Mailing Address - Country:US
Mailing Address - Phone:646-371-3561
Mailing Address - Fax:
Practice Address - Street 1:103 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:ATTLEBORO FALLS
Practice Address - State:MA
Practice Address - Zip Code:02763-1015
Practice Address - Country:US
Practice Address - Phone:508-699-0449
Practice Address - Fax:508-699-4344
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063595122300000X
MADL13593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY063595-01OtherNYS DENTAL LICENSE