Healthcare Provider Details

I. General information

NPI: 1790760700
Provider Name (Legal Business Name): JAY IBRAHIM HADDAD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JIHAD IBRAHIM HADDAD D.D.S.

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 MERCANTILE DR E STE 101
FREDERICK MD
21703-7656
US

IV. Provider business mailing address

7625 MAPLE LAWN BLVD SUITE 240
FULTON MD
20759-2565
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-0870
  • Fax: 301-694-7034
Mailing address:
  • Phone: 301-617-3404
  • Fax: 301-617-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13498
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: