Provider Demographics
NPI:1710945308
Name:AZZOUZ, ABRAHAM LAWRENCE (DDS)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:LAWRENCE
Last Name:AZZOUZ
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 1:24366 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3063
Mailing Address - Country:US
Mailing Address - Phone:313-535-2273
Mailing Address - Fax:313-535-5212
Practice Address - Street 1:24366 GRAND RIVER AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3063
Practice Address - Country:US
Practice Address - Phone:313-535-2273
Practice Address - Fax:313-535-5212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156751223G0001X
MI2902014138124Q00000X
126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered124Q00000XDental ProvidersDental Hygienist
Not Answered126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15675OtherDELTA
MI3197750Medicaid
873745OtherUNITED CONCORDIA
MID800185OtherBLUE CROSS BLUE SHEILD
MID800185OtherBLUE CROSS BLUE SHEILD