Provider Demographics
NPI:1497700272
Name:ABAZA, NABIL A (DMD)
Entity Type:Individual
Prefix:
First Name:NABIL
Middle Name:A
Last Name:ABAZA
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 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1321
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:207 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1500
Practice Address - Country:US
Practice Address - Phone:215-561-0562
Practice Address - Fax:215-561-0472
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019318L1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000767939Medicaid
PA000767939Medicaid