Provider Demographics
NPI:1508352907
Name:JIWANI, RIYAZ RAZAKALI (DMD)
Entity Type:Individual
Prefix:DR
First Name:RIYAZ
Middle Name:RAZAKALI
Last Name:JIWANI
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 1:6371 CRESTGATE LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8458
Mailing Address - Country:US
Mailing Address - Phone:404-966-8347
Mailing Address - Fax:
Practice Address - Street 1:2637 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6103
Practice Address - Country:US
Practice Address - Phone:770-651-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0157131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice