Provider Demographics
NPI:1831838572
Name:IDREES, HUSAM
Entity type:Individual
Prefix:
First Name:HUSAM
Middle Name:
Last Name:IDREES
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 1:110 ROCKY KNOB WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17554-1889
Mailing Address - Country:US
Mailing Address - Phone:717-203-2290
Mailing Address - Fax:
Practice Address - Street 1:100 CONTINENTAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2260
Practice Address - Country:US
Practice Address - Phone:717-367-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0435911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice