Healthcare Provider Details

I. General information

NPI: 1609306745
Provider Name (Legal Business Name): HEBA SHAMMOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 MING AVE
BAKERSFIELD CA
93304-4431
US

IV. Provider business mailing address

6300 WHEELER VALLEY LN
BAKERSFIELD CA
93311-9149
US

V. Phone/Fax

Practice location:
  • Phone: 661-396-1701
  • Fax:
Mailing address:
  • Phone: 559-300-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number101493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: