Provider Demographics
NPI:1457784407
Name:ELNAZER, MOHAMED HAZEM FARID
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:HAZEM FARID
Last Name:ELNAZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 GRAFTON ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604
Mailing Address - Country:US
Mailing Address - Phone:508-735-5488
Mailing Address - Fax:508-753-8048
Practice Address - Street 1:1438 GRAFTON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-2721
Practice Address - Country:US
Practice Address - Phone:508-753-5488
Practice Address - Fax:508-753-8048
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXETN1921223G0001X
MADN18566461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice