Provider Demographics
NPI:1801101407
Name:MOHAMAD, ASANA (DDS)
Entity type:Individual
Prefix:
First Name:ASANA
Middle Name:
Last Name:MOHAMAD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3014
Practice Address - Street 1:125 SCOTT ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52801-1130
Practice Address - Country:US
Practice Address - Phone:563-336-3222
Practice Address - Fax:563-336-3229
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1932193224Medicaid