Healthcare Provider Details

I. General information

NPI: 1265623417
Provider Name (Legal Business Name): DAVID MARK HAZZOURI SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S. 7TH AVE.
SCRANTON PA
18505
US

IV. Provider business mailing address

211 S. 7TH AVE.
SCRANTON PA
18505
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-6030
  • Fax: 570-961-6030
Mailing address:
  • Phone: 570-961-6030
  • Fax: 570-961-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS027711L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS027711L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: