Provider Demographics
NPI:1053797746
Name:MOHAMED, ABIGAIL JACKIE (DDS)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:JACKIE
Last Name:MOHAMED
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 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:2327 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1851
Practice Address - Country:US
Practice Address - Phone:541-889-0052
Practice Address - Fax:541-889-0990
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10309122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist