=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811630585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOAYAD ADNAN ZAWAHRA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2022
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 S IDAHO RD STE 100
-----------------------------------------------------
City | APACHE JUNCTION
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85119-0006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-867-4586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4906 E BROWN RD UNIT 8
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-4263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-415-4612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D011456
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------