Provider Demographics
NPI:1730479361
Name:AZAB, SAMEH E (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMEH
Middle Name:E
Last Name:AZAB
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 1:1101 S AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3888
Mailing Address - Country:US
Mailing Address - Phone:262-637-9371
Mailing Address - Fax:
Practice Address - Street 1:1101 S AIRLINE RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3888
Practice Address - Country:US
Practice Address - Phone:262-637-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6706-15122300000X
IL019028686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist