Provider Demographics
NPI:1801067293
Name:GHATTAS, MAZEN S (DMD)
Entity type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:S
Last Name:GHATTAS
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 1:42 CHERRY HLS
Mailing Address - Street 2:
Mailing Address - City:JERSEY VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:77064-4072
Mailing Address - Country:US
Mailing Address - Phone:832-294-8123
Mailing Address - Fax:
Practice Address - Street 1:4061 BELLAIRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1121
Practice Address - Country:US
Practice Address - Phone:713-664-1337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0281344Medicaid