=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851286389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUTAHARA AZEEZA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2025
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3483 W FM 544 STE 112
-----------------------------------------------------
City | WYLIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75098-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-913-6744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 SIERRA BLANCA PASS
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75063-4649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-913-6744
-----------------------------------------------------
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 | 41436
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------