Provider Demographics
NPI:1104913805
Name:HASSAM, RIYAZALI (DMD)
Entity type:Individual
Prefix:DR
First Name:RIYAZALI
Middle Name:
Last Name:HASSAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1645
Mailing Address - Country:US
Mailing Address - Phone:732-747-9232
Mailing Address - Fax:732-747-9234
Practice Address - Street 1:96 W FRONT ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1645
Practice Address - Country:US
Practice Address - Phone:732-747-9232
Practice Address - Fax:732-747-9234
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01982200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist