Healthcare Provider Details

I. General information

NPI: 1548107253
Provider Name (Legal Business Name): MOHAMAD EZZAT ABOU EL NASR ORTHODONTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 ROBERTS DR STE 100
SANDY SPRINGS GA
30350-4150
US

IV. Provider business mailing address

6919 PEACHTREE DUNWOODY RD APT 418
SANDY SPRINGS GA
30328
US

V. Phone/Fax

Practice location:
  • Phone: 770-504-4519
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN122653
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: