Basic Information
| Provider Information | |||||||||
| NPI: | 1194210849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILSHAHUOME | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 ARLINGTON ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021493809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6463713561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DL13593 | MA | Y | Dental Providers | Dentist |
No ID Information.