Basic Information
| Provider Information | |||||||||
| NPI: | 1497700272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABAZA | ||||||||
| FirstName: | NABIL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191071500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155610562 | ||||||||
| FaxNumber: | 2155610472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DS019318L | PA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | DS019318L | PA | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000767939 | 05 | PA | MEDICAID |