Healthcare Provider Details

I. General information

NPI: 1558744912
Provider Name (Legal Business Name): ELIAS HADDAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 COBB PKWY SE STE 100
ATLANTA GA
30339-3519
US

IV. Provider business mailing address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

V. Phone/Fax

Practice location:
  • Phone: 770-240-0328
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600896
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN122827
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: