Provider Demographics
NPI:1578116968
Name:AL AZZAWI, MOHAMMED MAHMOOD (BDS, MS, MS, PHD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:MAHMOOD
Last Name:AL AZZAWI
Suffix:
Gender:M
Credentials:BDS, MS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13210 LAGUNA SHORES DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-6748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4179 DOWLEN RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6852
Practice Address - Country:US
Practice Address - Phone:916-595-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416654122300000X
TX354801223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35480OtherDENTAL LICENCE