Provider Demographics
NPI:1376172379
Name:MUWAFAQ, HUSAM (SAM) (DMD)
Entity type:Individual
Prefix:DR
First Name:HUSAM (SAM)
Middle Name:
Last Name:MUWAFAQ
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 1:150 MOUNT VERNON DR STE 201
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1410
Mailing Address - Country:US
Mailing Address - Phone:859-317-3864
Mailing Address - Fax:
Practice Address - Street 1:150 MOUNT VERNON DR STE 201
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1410
Practice Address - Country:US
Practice Address - Phone:859-317-3864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY104761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program