Healthcare Provider Details

I. General information

NPI: 1205247798
Provider Name (Legal Business Name): NOUREDDIN KHAZAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR
CLEVELAND OH
44109-1998
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1998
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-7800
  • Fax:
Mailing address:
  • Phone: 216-778-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30.24871
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: