Healthcare Provider Details

I. General information

NPI: 1649670431
Provider Name (Legal Business Name): SAHAWANEH DENTAL CORPORATON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12027 CENTRAL AVE
CHINO CA
91710-1908
US

IV. Provider business mailing address

100 SPECTRUM CENTER DR STE 100
IRVINE CA
92618-4962
US

V. Phone/Fax

Practice location:
  • Phone: 909-270-4291
  • Fax: 909-517-3023
Mailing address:
  • Phone: 714-578-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number55643
License Number StateCA

VIII. Authorized Official

Name: DR. SHOROUQ SAHAWNEH
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-578-6358