Healthcare Provider Details

I. General information

NPI: 1609252550
Provider Name (Legal Business Name): AMER AZZAM SHATTA B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 CORNELL ROAD CASE SCHOOL OF DENTAL MEDICINE, PERIODONTICS DEPARTMENT
CLEVELAND OH
44106
US

IV. Provider business mailing address

2124 CORNELL ROAD CASE SCHOOL OF DENTAL MEDICINE, PERIODONTICS DEPARTMENT
CLEVELAND OH
44106
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-6757
  • Fax: 216-368-3204
Mailing address:
  • Phone: 216-368-6757
  • Fax: 216-368-3204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES.3524
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: