Provider Demographics
NPI:1699875591
Name:AL-SABBAGH, MOHANAD (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MOHANAD
Middle Name:
Last Name:AL-SABBAGH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:D104
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-6193
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-6193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81481223G0001X, 1223P0300X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9177550Medicaid
KY60003340Medicaid
KY9177550Medicaid