Basic Information
| Provider Information | |||||||||
| NPI: | 1629716907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAWAZ | ||||||||
| FirstName: | MOHAMAD | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | VCUHS GMEA | ||||||||
| Address2: | BOX 980257 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232980257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
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| Practice Location | |||||||||
| Address1: | VCUHS DEPT OF OMFS RESIDENCY | ||||||||
| Address2: | 1250 E MARSHALL ST | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232980566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048280602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 0442000458 | VA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.