Provider Demographics
NPI:1487063053
Name:ZAKI, MINA
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:ZAKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CHURCH RD W STE 119
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7154
Mailing Address - Country:US
Mailing Address - Phone:662-253-8027
Mailing Address - Fax:662-253-8067
Practice Address - Street 1:1100 CHURCH RD W STE 119
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7154
Practice Address - Country:US
Practice Address - Phone:662-253-8027
Practice Address - Fax:662-253-8067
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3770-14122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist