Provider Demographics
NPI:1679162523
Name:FAWZY, MOURAD S (DDS)
Entity type:Individual
Prefix:
First Name:MOURAD
Middle Name:S
Last Name:FAWZY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2317
Mailing Address - Country:US
Mailing Address - Phone:805-979-3037
Mailing Address - Fax:
Practice Address - Street 1:5680 CALLE REAL
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2317
Practice Address - Country:US
Practice Address - Phone:626-364-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105947122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist