Healthcare Provider Details

I. General information

NPI: 1982994158
Provider Name (Legal Business Name): SHAMY DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 W UNION HILLS DR SUITE B18
GLENDALE AZ
85308-1643
US

IV. Provider business mailing address

4330 W UNION HILLS DR SUITE B18
GLENDALE AZ
85308-1643
US

V. Phone/Fax

Practice location:
  • Phone: 623-582-6666
  • Fax: 623-582-6665
Mailing address:
  • Phone: 623-582-6666
  • Fax: 623-582-6665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5167
License Number StateAZ

VIII. Authorized Official

Name: DR. GHASSA S SROUJIEH
Title or Position: OWNER
Credential: DDS
Phone: 623-582-6666