Provider Demographics
NPI:1285300020
Name:MUSTAFA, ETHAR (DDS)
Entity type:Individual
Prefix:
First Name:ETHAR
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 KENDALL DR STE B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-4315
Mailing Address - Country:US
Mailing Address - Phone:909-882-8882
Mailing Address - Fax:
Practice Address - Street 1:985 KENDALL DR STE B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-4315
Practice Address - Country:US
Practice Address - Phone:909-882-8882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist