Provider Demographics
NPI:1639293533
Name:ELGAZZAR, MOHAMED
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:
Last Name:ELGAZZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15412 EWELLS MILL WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5883
Mailing Address - Country:US
Mailing Address - Phone:860-930-1724
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM ST STE 615
Practice Address - Street 2:615
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3843
Practice Address - Country:US
Practice Address - Phone:703-734-1233
Practice Address - Fax:703-734-1331
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist