Healthcare Provider Details

I. General information

NPI: 1356624571
Provider Name (Legal Business Name): SENAIT HABTE GEBREWOLD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E DIAMOND AVE
EVANSVILLE IN
47711-3714
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE SUITE 290
MARIETTA GA
30067-6405
US

V. Phone/Fax

Practice location:
  • Phone: 812-461-2365
  • Fax:
Mailing address:
  • Phone: 678-904-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011734A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: