Provider Demographics
NPI:1699451633
Name:MOHSENI, MEDEA
Entity type:Individual
Prefix:
First Name:MEDEA
Middle Name:
Last Name:MOHSENI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FLEET ST NW APT H22
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-3821
Mailing Address - Country:US
Mailing Address - Phone:408-368-5747
Mailing Address - Fax:
Practice Address - Street 1:2515 E ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-3708
Practice Address - Country:US
Practice Address - Phone:940-696-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist