Provider Demographics
NPI:1245837152
Name:AL-DAGGISTANY, MARWAN S (DMD)
Entity type:Individual
Prefix:DR
First Name:MARWAN
Middle Name:S
Last Name:AL-DAGGISTANY
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 1:4451 AUTUMN SAGE DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1285
Mailing Address - Country:US
Mailing Address - Phone:210-421-3203
Mailing Address - Fax:
Practice Address - Street 1:4451 AUTUMN SAGE DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-1285
Practice Address - Country:US
Practice Address - Phone:210-421-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858846122300000X
TX367951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentist