Healthcare Provider Details

I. General information

NPI: 1831838572
Provider Name (Legal Business Name): HUSAM IDREES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CONTINENTAL DR
ELIZABETHTOWN PA
17022-2260
US

IV. Provider business mailing address

110 ROCKY KNOB WAY
MOUNTVILLE PA
17554-1889
US

V. Phone/Fax

Practice location:
  • Phone: 717-367-1336
  • Fax:
Mailing address:
  • Phone: 717-203-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS043591
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: