MEDICARE: AFFORDABLE DENTURES - FOREST PARK, NOUREDDIN KHAZAM, DDS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1518598002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFORDABLE DENTURES - FOREST PARK, NOUREDDIN KHAZAM, DDS, INC.

Provider Business Mailing Address
First Line	:	1173 SMILEY AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-1832
Country	:	US
Telephone Number	:	513-648-9479
Fax Number	:

Provider Business Practice Location Address
First Line	:	1173 SMILEY AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-1832
Country	:	US
Telephone Number	:	513-648-9479
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NOUREDDIN KHAZAM
Credential	:	DDS
Telephone Number	:	513-648-9479

Provider Enumeration Date	:	02/03/2020
Last Update Date	:	02/03/2020

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