Provider Demographics
NPI:1174365381
Name:IJAZ, SUMMIYA
Entity type:Individual
Prefix:
First Name:SUMMIYA
Middle Name:
Last Name:IJAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 CORWIN NIXON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45065-1248
Mailing Address - Country:US
Mailing Address - Phone:513-494-3111
Mailing Address - Fax:
Practice Address - Street 1:658 CORWIN NIXON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45065-1248
Practice Address - Country:US
Practice Address - Phone:513-494-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.028046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program