Healthcare Provider Details

I. General information

NPI: 1578477667
Provider Name (Legal Business Name): MOHAMMED AL QAZZAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4317 E MCDOWELL RD
PHOENIX AZ
85008-4501
US

IV. Provider business mailing address

118 N JOSHUA TREE LN
GILBERT AZ
85234-4437
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-0405
  • Fax:
Mailing address:
  • Phone: 602-410-5590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012847
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: