Provider Demographics
NPI:1356658942
Name:HAZBOUN, TAWFIQ
Entity Type:Individual
Prefix:
First Name:TAWFIQ
Middle Name:
Last Name:HAZBOUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAS JACKSONVILLE, BUILDING 54
Mailing Address - Street 2:BUREAU OF MEDICINE & SURGERY DETACHMENT JACKSONVILLE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6435 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1835
Practice Address - Country:US
Practice Address - Phone:716-662-7229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058438-1122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist