Provider Demographics
NPI:1093916819
Name:HADDAD, NELLY GUIRGIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NELLY
Middle Name:GUIRGIS
Last Name:HADDAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 GEORGE HECKER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3168
Mailing Address - Country:US
Mailing Address - Phone:386-756-6312
Mailing Address - Fax:
Practice Address - Street 1:3755A S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4233
Practice Address - Country:US
Practice Address - Phone:386-788-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist