Provider Demographics
NPI:1679555791
Name:SHEHATA, RIZK AMIN (DDS)
Entity Type:Individual
Prefix:
First Name:RIZK
Middle Name:AMIN
Last Name:SHEHATA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 G ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-743-2470
Mailing Address - Fax:215-232-7227
Practice Address - Street 1:4665 G ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120
Practice Address - Country:US
Practice Address - Phone:215-743-2470
Practice Address - Fax:215-232-7227
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0208834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00526265Medicaid