Provider Demographics
NPI:1972596492
Name:MAZZAWI, MARTY (DDS)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:
Last Name:MAZZAWI
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0365
Mailing Address - Country:US
Mailing Address - Phone:770-972-4436
Mailing Address - Fax:770-985-8810
Practice Address - Street 1:2268 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3498
Practice Address - Country:US
Practice Address - Phone:770-972-4436
Practice Address - Fax:770-985-8810
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice