Provider Demographics
NPI:1356364665
Name:MAZZAWI, JEFFREY MILES (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MILES
Last Name:MAZZAWI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WALESKA RD.
Mailing Address - Street 2:SUITE 2-B
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-1717
Mailing Address - Fax:770-479-1747
Practice Address - Street 1:205 WALESKA RD
Practice Address - Street 2:SUITE 2-B
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-479-1717
Practice Address - Fax:770-479-1747
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA686404389AMedicaid