Provider Demographics
NPI:1114581824
Name:HEJAZIN, NOUR
Entity Type:Individual
Prefix:
First Name:NOUR
Middle Name:
Last Name:HEJAZIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 MAIN ST APT 338
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8178
Mailing Address - Country:US
Mailing Address - Phone:773-231-4561
Mailing Address - Fax:
Practice Address - Street 1:950 HIGH ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8223
Practice Address - Country:US
Practice Address - Phone:330-331-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0266451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program