Basic Information
Provider Information
NPI: 1801272315
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NASSIF
FirstName: MOHAMAD
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1090 NORTHCHASE PKWY SE STE 290
Address2:  
City: MARIETTA
State: GA
PostalCode: 300676402
CountryCode: US
TelephoneNumber: 7709167039
FaxNumber:  
Practice Location
Address1: 5900 E VA BEACH BLVD STE 70
Address2:  
City: NORFOLK
State: VA
PostalCode: 235022514
CountryCode: US
TelephoneNumber: 7576444356
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/06/2015
LastUpdateDate: 06/08/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X0401414923VAY Dental ProvidersDentistGeneral Practice

No ID Information.


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