Provider Demographics
NPI:1417389172
Name:ELAZIZI, MOHAMAD (BDS, MSC)
Entity Type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:
Last Name:ELAZIZI
Suffix:
Gender:M
Credentials:BDS, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 FLORIDA AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2439
Mailing Address - Country:US
Mailing Address - Phone:321-632-3171
Mailing Address - Fax:
Practice Address - Street 1:1281 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2439
Practice Address - Country:US
Practice Address - Phone:321-632-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20817122300000X
MI2901021068122300000X
FLDN208171223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist