Provider Demographics
NPI:1801622683
Name:AL TARAWNEH, HAZEM MOFREH
Entity type:Individual
Prefix:DR
First Name:HAZEM
Middle Name:MOFREH
Last Name:AL TARAWNEH
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:HAZEM
Other - Middle Name:MOFREH DAKHILALLAH
Other - Last Name:ALTARAWNEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1957 W CREEKSIDE CROSSING CIR APT 210
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-5699
Mailing Address - Country:US
Mailing Address - Phone:414-241-0859
Mailing Address - Fax:
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI843718751223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics