Healthcare Provider Details

I. General information

NPI: 1780733014
Provider Name (Legal Business Name): AVRAHAM MIZRACHI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7274 CRADLEROCK WAY
COLUMBIA MD
21045-5069
US

IV. Provider business mailing address

7274 CRADLEROCK WAY
COLUMBIA MD
21045-5069
US

V. Phone/Fax

Practice location:
  • Phone: 410-381-0505
  • Fax: 410-381-0902
Mailing address:
  • Phone: 410-381-0505
  • Fax: 410-381-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11762
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: