Provider Demographics
NPI:1629358569
Name:ELBIALY, HAZEM (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAZEM
Middle Name:
Last Name:ELBIALY
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:SCHOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:12157-0129
Mailing Address - Country:US
Mailing Address - Phone:518-702-4145
Mailing Address - Fax:518-702-4195
Practice Address - Street 1:107 PROSPECT ST STE 1
Practice Address - Street 2:
Practice Address - City:SCHOHARIE
Practice Address - State:NY
Practice Address - Zip Code:12157-3204
Practice Address - Country:US
Practice Address - Phone:518-702-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056403122300000X, 1223G0001X
MADN18558041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03503275Medicaid