Provider Demographics
NPI:1811616113
Name:ISHFAQ, MOMINA
Entity type:Individual
Prefix:
First Name:MOMINA
Middle Name:
Last Name:ISHFAQ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 NORTHCREEK CIR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-1315
Mailing Address - Country:US
Mailing Address - Phone:650-797-7551
Mailing Address - Fax:
Practice Address - Street 1:3000 DANVILLE BLVD STE A&B
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507-1574
Practice Address - Country:US
Practice Address - Phone:925-820-2688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist