1801067293 NPI number — DR. MAZEN S. GHATTAS DMD

Table of content: DR. MAZEN S. GHATTAS DMD (NPI 1801067293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801067293 NPI number — DR. MAZEN S. GHATTAS DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHATTAS
Provider First Name:
MAZEN
Provider Middle Name:
S.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801067293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42 CHERRY HLS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JERSEY VILLAGE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77064-4072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-294-8123
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4061 BELLAIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77025-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-664-1337
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  18607 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0281344 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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