Provider Demographics
NPI:1891707428
Name:MAKSOUD, MOHAMED A (DMD PA)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:A
Last Name:MAKSOUD
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9191 R G SKINNER PKWY #404
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-731-4347
Mailing Address - Fax:904-731-4310
Practice Address - Street 1:9191 R G SKINNER PKWY #404
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-731-4347
Practice Address - Fax:904-731-4310
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2546851223P0300X
FLDN120161223P0300X
FL120161223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics