Healthcare Provider Details

I. General information

NPI: 1306170055
Provider Name (Legal Business Name): ALBERT A HAZZOURI JR DDS, MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LACKAWANNA AVE SUITE 300
SCRANTON PA
18503-2046
US

IV. Provider business mailing address

600 LACKAWANNA AVE SUITE 300
SCRANTON PA
18503-2046
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-9136
  • Fax: 570-344-0299
Mailing address:
  • Phone: 570-342-9136
  • Fax: 570-344-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS023426
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036530
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS024299L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ALBERT A HAZZOURI JR.
Title or Position: OWNER
Credential: DDS, MS
Phone: 570-342-9136