MEDICARE: EHAB FAYEK ISMAIL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	47102	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D47102	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1699920678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EHAB FAYEK ISMAIL DDS

Provider Business Mailing Address
First Line	:	2641 HAMNER AVE
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3636
Country	:	US
Telephone Number	:	562-968-4061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 HAMNER AVE
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3636
Country	:	US
Telephone Number	:	562-968-4061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/24/2020

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