Healthcare Provider Details

I. General information

NPI: 1245257898
Provider Name (Legal Business Name): HUSAM MOHAMAD BEZREH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MOHAMAD HUSAM ALBZREH DMD

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GALLERIA PKWY SE STE 250
ATLANTA GA
30339-8127
US

IV. Provider business mailing address

100 GALLERIA PKWY SE STE 250
ATLANTA GA
30339-8127
US

V. Phone/Fax

Practice location:
  • Phone: 678-236-0500
  • Fax: 678-236-0586
Mailing address:
  • Phone: 678-236-0500
  • Fax: 678-236-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013014
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: