Provider Demographics
NPI:1316624158
Name:AHMAD, MOHAMMAD R (DMD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:R
Last Name:AHMAD
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 1:304 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2908
Mailing Address - Country:US
Mailing Address - Phone:708-590-9424
Mailing Address - Fax:
Practice Address - Street 1:1515 W 45TH AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-3801
Practice Address - Country:US
Practice Address - Phone:219-922-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034303122300000X
IN12014139A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist