Active NPI
Jeffrey Miles Mazzawi, DMD
- Pediatric Dentistry
- Canton, GA
National Provider Identifier
1356364665
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- DN012359
- Practice address
- 205 Waleska Rd
Suite 2-B
Canton, GA 30114 - Phone
- (770) 479-1717
- Fax
- (770) 479-1747
- NPI assigned
- Jul 26, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | DN012359 | GA | Primary |
Addresses
Primary practice location
205 Waleska Rd
Suite 2-B
Canton, GA 30114
Mailing address
205 Waleska Rd.
Suite 2-B
Canton, GA 30114
Phone (770) 479-1717
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 686404389A | Medicaid | GA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN012359 | GA | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153872000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1449705600000",
"number": "1356364665",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "205 WALESKA RD.",
"address_2": "SUITE 2-B",
"city": "CANTON",
"state": "GA",
"postal_code": "30114",
"telephone_number": "770-479-1717",
"fax_number": "770-479-1747"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "205 WALESKA RD",
"address_2": "SUITE 2-B",
"city": "CANTON",
"state": "GA",
"postal_code": "30114",
"telephone_number": "770-479-1717",
"fax_number": "770-479-1747"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAZZAWI",
"first_name": "JEFFREY",
"middle_name": "MILES",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-26",
"last_updated": "2015-12-10",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "GA",
"license": "DN012359",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "686404389A",
"state": "GA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Canton, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.