Basic Information
| Provider Information | |||||||||
| NPI: | 1508956038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZZAWI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAZZAWI | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2645 CLAIRMONT RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706052520 | ||||||||
| FaxNumber: | 7709858810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2268 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709724436 | ||||||||
| FaxNumber: | 7709858810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN011705 | GA | Y | Dental Providers | Dentist | General Practice |
No ID Information.