Provider Demographics
NPI:1679669188
Name:GHANNIE, FAZEELA (DDS)
Entity type:Individual
Prefix:DR
First Name:FAZEELA
Middle Name:
Last Name:GHANNIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3194 CLUBSIDE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4722
Mailing Address - Country:US
Mailing Address - Phone:615-327-9195
Mailing Address - Fax:770-441-0299
Practice Address - Street 1:2000 RIVERSIDE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044
Practice Address - Country:US
Practice Address - Phone:678-836-2109
Practice Address - Fax:770-441-0299
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013167OtherDENTIST