Provider Demographics
NPI:1114213147
Name:ELGEZIRY, SAMEH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMEH
Middle Name:A
Last Name:ELGEZIRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 AZALEA POINT DR S
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4601
Mailing Address - Country:US
Mailing Address - Phone:904-273-9267
Mailing Address - Fax:
Practice Address - Street 1:184 AZALEA POINT DR S
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4601
Practice Address - Country:US
Practice Address - Phone:904-273-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 139681223G0001X
MADN 176641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice