Provider Demographics
NPI:1720123201
Name:ABUJAMRA, NICOLAS FAWZI (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:FAWZI
Last Name:ABUJAMRA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2581 DEVELOPMENT DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4247
Mailing Address - Country:US
Mailing Address - Phone:920-347-2626
Mailing Address - Fax:920-347-2621
Practice Address - Street 1:2581 DEVELOPMENT DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4247
Practice Address - Country:US
Practice Address - Phone:920-347-2626
Practice Address - Fax:920-347-2621
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4873-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist