Provider Demographics
NPI:1174094734
Name:ISLAM, MOHAMMED SHAFAYETUL
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:SHAFAYETUL
Last Name:ISLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E NEES AVE APT 133
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-6016
Mailing Address - Country:US
Mailing Address - Phone:703-945-5673
Mailing Address - Fax:
Practice Address - Street 1:2610 E NEES AVE APT 133
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-6016
Practice Address - Country:US
Practice Address - Phone:703-945-5673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice