Mamdouh Alrata, DDS
Individual provider Active NPI Dentist · Washington, MO
NPI 1902321367 · NPPES record last updated Feb 1, 2022
Key facts
- NPI
- 1902321367
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 2020037677 (MO)
- Practice address
- 3155 Phoenix Center Dr
Washington, MO 63090-5689 - Phone
- (630) 550-7406
- NPI assigned
- Aug 7, 2017
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170927002520 | IL | Order and Referring Only - Dentist |
3173897279 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2020037677 | MO | MD | Dentist |
| DE60694174 | WA | MD | Dentist |
Interoperability endpoints
- mamdough.alrata.p1@direct.affiniahealthcare.nextgenshare.com
- gabrielle.torgerson.p1@direct.affiniahealthcare.nextgenshare.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DE60694174 | WA | |
| Dentist | 122300000X | 2020037677 | MO | Yes |
Addresses
Primary practice location
3155 Phoenix Center Dr
Washington, MO 63090-5689
Mailing address
736 Carman Meadows Dr
Manchester, MO 63021-7100
Phone (630) 550-7406
Other providers in Washington, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 1, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.