Provider Demographics
NPI:1215453840
Name:SHEHAB, MOHAMED MAHMOUD HUSSIEN HA
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:MAHMOUD HUSSIEN HA
Last Name:SHEHAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9436 N SAYBROOK DR APT 129
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0640
Mailing Address - Country:US
Mailing Address - Phone:415-530-7408
Mailing Address - Fax:
Practice Address - Street 1:2740 S ELM AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-5435
Practice Address - Country:US
Practice Address - Phone:559-457-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101785122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist