Provider Demographics
NPI:1174522387
Name:MASHOD, SIAMAC (DDS)
Entity type:Individual
Prefix:DR
First Name:SIAMAC
Middle Name:
Last Name:MASHOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11190 MONUMENT LANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225
Mailing Address - Country:US
Mailing Address - Phone:904-645-9162
Mailing Address - Fax:904-998-8812
Practice Address - Street 1:11190 MONUMENT LANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4580
Practice Address - Country:US
Practice Address - Phone:904-645-9162
Practice Address - Fax:904-998-8812
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist