Provider Demographics
NPI:1902171838
Name:MOMIN, MOHMEDVASIM RASUL (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:MOHMEDVASIM
Middle Name:RASUL
Last Name:MOMIN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:DR
Other - First Name:VASIM
Other - Middle Name:RASUL
Other - Last Name:MOMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MD
Mailing Address - Street 1:2664 OLDE IVY LN
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5776
Mailing Address - Country:US
Mailing Address - Phone:404-514-8120
Mailing Address - Fax:
Practice Address - Street 1:7557 RAMBLER RD STE 111
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-2360
Practice Address - Country:US
Practice Address - Phone:469-729-5972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-10
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002038931223S0112X
TX338571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty