Healthcare Provider Details

I. General information

NPI: 1427300599
Provider Name (Legal Business Name): ADHAM ABDEL AZIM BDS, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 5TH ST
SAN FRANCISCO CA
94103-2919
US

IV. Provider business mailing address

240 SQUIRE HALL
BUFFALO NY
14214
US

V. Phone/Fax

Practice location:
  • Phone: 347-761-7570
  • Fax:
Mailing address:
  • Phone: 347-761-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number000062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: